Provider Demographics
NPI:1346983459
Name:FENN, AMANDA KIMBERLY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KIMBERLY
Last Name:FENN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:KIMBERLY
Other - Last Name:BURBANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8576 JASONVILLE CT SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8287
Mailing Address - Country:US
Mailing Address - Phone:847-858-9889
Mailing Address - Fax:
Practice Address - Street 1:1560 LEONARD ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5572
Practice Address - Country:US
Practice Address - Phone:616-460-7647
Practice Address - Fax:616-458-5430
Is Sole Proprietor?:No
Enumeration Date:2022-04-16
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health