Provider Demographics
NPI:1871027730
Name:CLARK, AMANDA KATHALEEN (LADC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHALEEN
Last Name:CLARK
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 E HOWARD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-1714
Mailing Address - Country:US
Mailing Address - Phone:218-262-0860
Mailing Address - Fax:218-447-7299
Practice Address - Street 1:522 E HOWARD ST STE 101
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-1714
Practice Address - Country:US
Practice Address - Phone:218-262-0860
Practice Address - Fax:218-447-7299
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301773101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)