Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | 34005212A | IN |
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 34005212A | IN |
N | 101YM0800X | Mental Health Counselor | 34005212A | IN |
N | 1041C0700X | Clinical Social Worker | 34005212A | IN |
NPI | 1003905738 |
---|---|
Provider Name | Amanda Barge |
First Address | Bloomington, IN 47403-2353 |
Second Address | Bloomington, IN 47403-2353 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/10/2006 |
Last Update Date | 08/07/2007 |