Provider Demographics
NPI:1629835046
Name:OUELLETTE, AMANDA J
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 RANKIN RD
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-9223
Mailing Address - Country:US
Mailing Address - Phone:503-577-0621
Mailing Address - Fax:
Practice Address - Street 1:32 SHAFER AVE
Practice Address - Street 2:
Practice Address - City:NACHES
Practice Address - State:WA
Practice Address - Zip Code:98937-9744
Practice Address - Country:US
Practice Address - Phone:509-653-1586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61492659101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health