Provider Demographics
NPI:1346789179
Name:EDSTROM, AME MAE (LLMFT)
Entity Type:Individual
Prefix:MS
First Name:AME
Middle Name:MAE
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4507 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:HERSEY
Mailing Address - State:MI
Mailing Address - Zip Code:49639-8785
Mailing Address - Country:US
Mailing Address - Phone:231-832-2234
Mailing Address - Fax:231-832-0385
Practice Address - Street 1:4507 170TH AVE
Practice Address - Street 2:
Practice Address - City:HERSEY
Practice Address - State:MI
Practice Address - Zip Code:49639-8785
Practice Address - Country:US
Practice Address - Phone:231-832-2234
Practice Address - Fax:231-832-0385
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006505106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist