Provider Demographics
NPI:1407349269
Name:MILLER, AMANDA JANE (LLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:MILLER
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JANE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:3225 N EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9334
Practice Address - Country:US
Practice Address - Phone:163-641-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X, 1041C0700X
MI6361006485103T00000X
MI63010166133747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical