Healthcare Provider Details

I. General information

NPI: 1720996069
Provider Name (Legal Business Name): AMANDA A LA BODE SAC-IT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 S 108TH ST
WEST ALLIS WI
53227-3224
US

IV. Provider business mailing address

8444 N 90TH ST STE 100
SCOTTSDALE AZ
85258-4437
US

V. Phone/Fax

Practice location:
  • Phone: 414-885-3525
  • Fax: 262-643-4617
Mailing address:
  • Phone: 602-248-8886
  • Fax: 602-854-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21133-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: