Provider Demographics
NPI:1073167235
Name:PALMER, AMANDA RAYE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAYE
Last Name:PALMER
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 1:581 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-2444
Mailing Address - Country:US
Mailing Address - Phone:810-407-4882
Mailing Address - Fax:
Practice Address - Street 1:5505 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-2614
Practice Address - Country:US
Practice Address - Phone:313-224-0715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016693101YP2500X
MI6401018845101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional