Individual
AMANDA MARIE WALLACE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LCSW
Contact information
Practice address
205 MAIN ST E, MOHALL, ND 58761-4014
(701) 756-6374
Mailing address
PO BOX 305, MOHALL, ND 58761-0305
(701) 756-6374
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
4524
ND
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1473894
—
ND
Enumeration date
04/06/2018
Last updated
04/06/2018
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