Provider Demographics
NPI:1083990626
Name:MIRA-AMAYA, LISSETTE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LISSETTE
Middle Name:
Last Name:MIRA-AMAYA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 LAKE STREET
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3097
Mailing Address - Country:US
Mailing Address - Phone:269-775-1414
Mailing Address - Fax:269-344-0285
Practice Address - Street 1:930 LAKE STREET
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-3097
Practice Address - Country:US
Practice Address - Phone:269-775-1414
Practice Address - Fax:269-344-0285
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010206891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3402136Medicaid