Provider Demographics
NPI:1124540695
Name:DEAN, AMANDA (CLC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DEAN
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:
Mailing Address - City:HYGIENE
Mailing Address - State:CO
Mailing Address - Zip Code:80533-0411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 CARNATION CIR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-7543
Practice Address - Country:US
Practice Address - Phone:303-601-5689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-16
Last Update Date:2017-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO254950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty