Provider Demographics
NPI:1265147623
Name:WILLIS-MARTIN, AMANDA (LADC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WILLIS-MARTIN
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-6151
Practice Address - Country:US
Practice Address - Phone:218-333-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306564101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)