Healthcare Provider Details

I. General information

NPI: 1477007250
Provider Name (Legal Business Name): AMANDA M MCMAHON LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7795 SAINT GERTRUDE AVE
RALEIGH ND
58564-4103
US

IV. Provider business mailing address

200 HIGHWAY 2 W
DEVILS LAKE ND
58301-3532
US

V. Phone/Fax

Practice location:
  • Phone: 701-597-3419
  • Fax:
Mailing address:
  • Phone: 701-656-2200
  • Fax: 701-665-2300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1801
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: