Provider Demographics
NPI:1093878407
Name:KEAS, AMY L (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:KEAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1843 RW BERENDS DR SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4955
Mailing Address - Country:US
Mailing Address - Phone:616-773-2908
Mailing Address - Fax:616-532-3046
Practice Address - Street 1:1843 RW BERENDS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4955
Practice Address - Country:US
Practice Address - Phone:616-773-2908
Practice Address - Fax:616-532-3046
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007991101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1712452Medicaid
MI20386Medicare UPIN
MI750910904Medicare UPIN
MI750910910Medicare UPIN
MI20351Medicare UPIN
MI20366Medicare UPIN
MIOP22320Medicare ID - Type Unspecified
MI1712452Medicaid
MI750910903Medicare UPIN
MI20378Medicare UPIN
MI750910902Medicare UPIN