Provider Demographics
NPI:1851963748
Name:VESTAL, AMANDA (LPCC, LADC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VESTAL
Suffix:
Gender:F
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11417 LILY ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2704
Mailing Address - Country:US
Mailing Address - Phone:612-423-0575
Mailing Address - Fax:
Practice Address - Street 1:299 COON RAPIDS BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5869
Practice Address - Country:US
Practice Address - Phone:651-240-2206
Practice Address - Fax:612-466-5677
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305175101YA0400X
MNCC04032101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)