MEDICARE: AMANDA DUSATKO

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	BBH-ACLC-LIC-54933	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BBH-ACLC-LIC-54933	OTHER	MT	STATE LICENSE

General Provider Information

NPI Number	:	1174284384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA DUSATKO

Provider Business Mailing Address
First Line	:	21 MASTIN RD
Second Line	:
City	:	KINSEY
State	:	MT
Zip	:	59338-9001
Country	:	US
Telephone Number	:	307-240-0959
Fax Number	:

Provider Business Practice Location Address
First Line	:	2911 WILSON ST
Second Line	:
City	:	MILES CITY
State	:	MT
Zip	:	59301-5722
Country	:	US
Telephone Number	:	406-234-2929
Fax Number	:	406-234-2928

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

Provider Enumeration Date	:	01/10/2022
Last Update Date	:	01/10/2022

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