Provider Demographics
NPI:1063696300
Name:VASKE, AMANDA JEAN (MA, LMFT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:VASKE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 HIGHWAY 96 E STE 211
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3619
Mailing Address - Country:US
Mailing Address - Phone:651-329-1266
Mailing Address - Fax:651-846-5312
Practice Address - Street 1:1310 HIGHWAY 96 E STE 211
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3619
Practice Address - Country:US
Practice Address - Phone:651-329-1266
Practice Address - Fax:651-846-5312
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1770106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist