Provider Demographics
NPI:1265007637
Name:DESANTIS, AMANDA JOANNE (MA, TLLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOANNE
Last Name:DESANTIS
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24365 BUCHANAN CT APT 1943
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2147
Mailing Address - Country:US
Mailing Address - Phone:718-887-5602
Mailing Address - Fax:
Practice Address - Street 1:1777 AXTELL DR STE 100
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4400
Practice Address - Country:US
Practice Address - Phone:248-787-3831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000397103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical