Provider Demographics
NPI:1306186812
Name:CISSE, AMANDA LYNN (MSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:CISSE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9249 W LAKE CITY RD
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9602
Mailing Address - Country:US
Mailing Address - Phone:989-422-5122
Mailing Address - Fax:
Practice Address - Street 1:439 S ROSS ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:MI
Practice Address - Zip Code:48612-9101
Practice Address - Country:US
Practice Address - Phone:989-422-5122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010917991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical