Provider Demographics
NPI:1528577814
Name:KOUBA, AMANDA JEAN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JEAN
Last Name:KOUBA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 46TH AVE SE STE 201
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-4829
Mailing Address - Country:US
Mailing Address - Phone:701-699-4052
Mailing Address - Fax:701-989-7030
Practice Address - Street 1:919 S 7TH ST STE 401
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5835
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND51561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical