Provider Demographics
NPI:1437434594
Name:GIBSON, AMANDA RENEE (MA, LLPC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RENEE
Last Name:GIBSON
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 1:850 W UNIVERSITY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1852
Mailing Address - Country:US
Mailing Address - Phone:248-990-2300
Mailing Address - Fax:
Practice Address - Street 1:850 W UNIVERSITY DR
Practice Address - Street 2:SUITE C
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1852
Practice Address - Country:US
Practice Address - Phone:248-990-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012606101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor