Provider Demographics
NPI:1174284384
Name:DUSATKO, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DUSATKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MASTIN RD
Mailing Address - Street 2:
Mailing Address - City:KINSEY
Mailing Address - State:MT
Mailing Address - Zip Code:59338-9001
Mailing Address - Country:US
Mailing Address - Phone:307-240-0959
Mailing Address - Fax:
Practice Address - Street 1:2911 WILSON ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5722
Practice Address - Country:US
Practice Address - Phone:406-234-2929
Practice Address - Fax:406-234-2928
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-ACLC-LIC-54933101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBBH-ACLC-LIC-54933OtherSTATE LICENSE