Provider Demographics
NPI:1255851630
Name:STEPHENSON, AMANDA L
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:STEPHENSON
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 1:520 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3838
Mailing Address - Country:US
Mailing Address - Phone:810-455-0102
Mailing Address - Fax:
Practice Address - Street 1:520 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3838
Practice Address - Country:US
Practice Address - Phone:810-455-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851115227104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker