Provider Demographics
NPI:1669881785
Name:CAPTAIN, AMANDA KNUDTSON
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KNUDTSON
Last Name:CAPTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:KNUDTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1137 N SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4234
Mailing Address - Country:US
Mailing Address - Phone:608-421-3239
Mailing Address - Fax:608-270-2238
Practice Address - Street 1:1191 N SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4234
Practice Address - Country:US
Practice Address - Phone:608-421-3239
Practice Address - Fax:608-270-2238
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI389-228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health