Provider Demographics
NPI:1467647412
Name:RAMTAHAL, AMANDA CRYSTAL-DAWN (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:CRYSTAL-DAWN
Last Name:RAMTAHAL
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:CRYSTAL-DAWN
Other - Last Name:HISCOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLMSW
Mailing Address - Street 1:P.O. BOX 249
Mailing Address - Street 2:801 HAZEN STREET
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-3474
Practice Address - Street 1:57418 CR. 681
Practice Address - Street 2:SUITE C.
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057
Practice Address - Country:US
Practice Address - Phone:269-621-6251
Practice Address - Fax:269-621-6044
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801086556104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker