Provider Demographics
NPI:1326408238
Name:KERBAWY, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KERBAWY
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 1:495 DEER PATH TRL
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-4350
Mailing Address - Country:US
Mailing Address - Phone:651-334-4473
Mailing Address - Fax:
Practice Address - Street 1:6548 TOWN CENTER DR STE D
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-382-8207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015992103TC0700X, 103TC1900X
MI6301016872103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling