Provider Demographics
NPI:1477161354
Name:SMITH, AMANDA JEAN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 RIDGELAND CT APT 1
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-8040
Mailing Address - Country:US
Mailing Address - Phone:269-352-2027
Mailing Address - Fax:
Practice Address - Street 1:854 WASHINGTON AVE STE 600
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7141
Practice Address - Country:US
Practice Address - Phone:616-604-8492
Practice Address - Fax:616-604-8493
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician