Provider Demographics
NPI:1760771034
Name:SIMONSON, AMANDA MARIE (LADC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:SIMONSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38873 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANCH
Mailing Address - State:MN
Mailing Address - Zip Code:55056-6079
Mailing Address - Country:US
Mailing Address - Phone:651-401-3068
Mailing Address - Fax:651-674-2534
Practice Address - Street 1:38873 14TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MN
Practice Address - Zip Code:55056-6079
Practice Address - Country:US
Practice Address - Phone:651-401-3068
Practice Address - Fax:651-674-2534
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303037101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)