Provider Demographics
NPI:1881098226
Name:MALONE, AMANDA SUE (CAC III)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:SUE
Last Name:MALONE
Suffix:
Gender:F
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 23RD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1114
Mailing Address - Country:US
Mailing Address - Phone:303-245-0123
Mailing Address - Fax:303-245-0119
Practice Address - Street 1:850 23RD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1114
Practice Address - Country:US
Practice Address - Phone:303-245-0123
Practice Address - Fax:030-245-0119
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0020826101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)