Provider Demographics
NPI:1427422815
Name:LADD, AMELIA (MS)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:LADD
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 SE POWELL BLVD.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202
Mailing Address - Country:US
Mailing Address - Phone:503-234-9591
Mailing Address - Fax:
Practice Address - Street 1:120 LABREE AVE S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2819
Practice Address - Country:US
Practice Address - Phone:218-683-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
MNLP6462103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program