Provider Demographics
NPI:1952808024
Name:WALLACE, AMANDA MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:LCSW
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 305
Mailing Address - Street 2:
Mailing Address - City:MOHALL
Mailing Address - State:ND
Mailing Address - Zip Code:58761-0305
Mailing Address - Country:US
Mailing Address - Phone:701-756-6374
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MOHALL
Practice Address - State:ND
Practice Address - Zip Code:58761-4014
Practice Address - Country:US
Practice Address - Phone:701-756-6374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4524171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1473894Medicaid