Provider Demographics
NPI:1043732720
Name:STREET, AMANDA (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E CASS ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1409
Mailing Address - Country:US
Mailing Address - Phone:616-450-7466
Mailing Address - Fax:
Practice Address - Street 1:12265 JAMES ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8613
Practice Address - Country:US
Practice Address - Phone:616-393-5682
Practice Address - Fax:616-393-5682
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801101351171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator