Basic Information
| Provider Information | |||||||||
| NPI: | 1619246063 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | ROXANNE | ||||||||
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| Credential: | CHA-III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 BACK STREET | ||||||||
| Address2: | |||||||||
| City: | SHUNGNAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074372138 | ||||||||
| FaxNumber: | 9074372139 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | AMBLER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997860110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074452129 | ||||||||
| FaxNumber: | 9074452179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2011 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 172V00000X | 11-1129-II | AK | N | Other Service Providers | Community Health Worker |
No ID Information.