Provider Demographics
NPI:1477602779
Name:LIS, AMANDA L (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:LIS
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:GRIMMETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LMFT
Mailing Address - Street 1:8041 STONEHAM CT
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-6435
Mailing Address - Country:US
Mailing Address - Phone:704-421-4887
Mailing Address - Fax:
Practice Address - Street 1:360 N CASWELL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2442
Practice Address - Country:US
Practice Address - Phone:704-421-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1139106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6105139Medicaid