MEDICARE: MISS AMANDA RAYE LINAN LSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1083962054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMANDA RAYE LINAN LSW

Provider Business Mailing Address
First Line	:	1333 IRIS AVE
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80304-2226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7710 N UNION BLVD STE 202
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-4085
Country	:	US
Telephone Number	:	719-494-7412
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2012
Last Update Date	:	06/14/2019

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