| NPI | 1679395016 |
|---|---|
| Former Name | AMANDA JO BLACKHALL |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 20695-130) |
| Enumeration Date | 2024-10-28 |
| Last Update Date | 2024-10-28 |