Provider Demographics
NPI:1508428772
Name:FIALKOFF, AMY M (LMSW)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:M
Last Name:FIALKOFF
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:SHANAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 ESPANOLA AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-1102
Mailing Address - Country:US
Mailing Address - Phone:269-532-8234
Mailing Address - Fax:
Practice Address - Street 1:4625 BECKLEY RD
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-7948
Practice Address - Country:US
Practice Address - Phone:269-979-8119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
68010908971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801090897Medicaid