Provider Demographics
NPI:1538941273
Name:BLACK, AMANDA LOUISE (SUDPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:BLACK
Suffix:
Gender:F
Credentials:SUDPT
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 1371
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0340
Mailing Address - Country:US
Mailing Address - Phone:360-266-5585
Mailing Address - Fax:
Practice Address - Street 1:230 E STATE ST
Practice Address - Street 2:
Practice Address - City:MOSSYROCK
Practice Address - State:WA
Practice Address - Zip Code:98564-2501
Practice Address - Country:US
Practice Address - Phone:360-266-5585
Practice Address - Fax:360-262-6620
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61208402101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)