Provider Demographics
NPI:1336657949
Name:CONDIC, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CONDIC
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 1:1370 N OAKLAND BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1572
Mailing Address - Country:US
Mailing Address - Phone:248-666-8870
Mailing Address - Fax:248-666-5023
Practice Address - Street 1:1370 N OAKLAND BLVD STE 105
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1572
Practice Address - Country:US
Practice Address - Phone:248-666-8870
Practice Address - Fax:248-666-5023
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI6401016923101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program