Healthcare Provider Details

I. General information

NPI: 1861004822
Provider Name (Legal Business Name): AMANDA JANE LIND LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE BLDG 2
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

808 N 3RD ST
GOSHEN IN
46528-7100
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-8190
  • Fax:
Mailing address:
  • Phone: 574-534-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM-11869
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: