# CLEANSLATE CENTERS, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1629398433
- **Authorized official:** MS. AMANDA L WILSON MD (OWNER)
- **Authorized official phone:** (413) 788-0100

## Contact information

- **Practice address:** 82 MAIN ST, WEST SPRINGFIELD, MA 01089-3942
- **Practice address phone:** (413) 788-0100
- **Practice address fax:** (413) 736-1813
- **Mailing address:** PO BOX 32, NORTHAMPTON, MA 01061
- **Mailing address phone:** (413) 788-0100
- **Mailing address fax:** (413) 736-1813

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YM0800X | Mental Health Counselor | — | NULL | — |
| 101YM0800X | Mental Health Counselor | — | — | — |
| 103TA0400X | Addiction (Substance Use Disorder) Psychologist | — | NULL | — |
| 103TA0400X | Addiction (Substance Use Disorder) Psychologist | — | — | — |
| 104100000X | Social Worker | — | NULL | — |
| 104100000X | Social Worker | — | — | — |
| 207RA0401X | Addiction Medicine (Internal Medicine) Physician | — | NULL | Yes |
| 207RA0401X | Addiction Medicine (Internal Medicine) Physician | — | — | Yes |
| 2084A0401X | Addiction Medicine (Psychiatry & Neurology) Physician | — | NULL | — |
| 2084A0401X | Addiction Medicine (Psychiatry & Neurology) Physician | — | — | — |

## Other

- **Enumeration date:** 06/03/2010
- **Last updated:** 06/09/2010