Provider Demographics
NPI:1679168876
Name:NUSBAUM, AMANDA (LPCC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:NUSBAUM
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9298 CENTRAL AVE NE STE 306
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4219
Mailing Address - Country:US
Mailing Address - Phone:651-955-4633
Mailing Address - Fax:
Practice Address - Street 1:9298 CENTRAL AVE NE STE 306
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4219
Practice Address - Country:US
Practice Address - Phone:651-955-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02768101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional