Provider Demographics
NPI:1407296791
Name:LOCKE, AMANDA L (MA, LLPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:LOCKE
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6549 TOWN CENTER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4824
Mailing Address - Country:US
Mailing Address - Phone:248-620-6400
Mailing Address - Fax:249-620-6405
Practice Address - Street 1:42669 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5036
Practice Address - Country:US
Practice Address - Phone:586-412-5321
Practice Address - Fax:586-412-5327
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional