Healthcare Provider Details

I. General information

NPI: 1952808024
Provider Name (Legal Business Name): AMANDA MARIE WALLACE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MAIN ST E
MOHALL ND
58761-4014
US

IV. Provider business mailing address

PO BOX 305
MOHALL ND
58761-0305
US

V. Phone/Fax

Practice location:
  • Phone: 701-756-6374
  • Fax:
Mailing address:
  • Phone: 701-756-6374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number4524
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: