Provider Demographics
NPI:1568838308
Name:DEVELLIS, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DEVELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:RZEPKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 663
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48143-0663
Mailing Address - Country:US
Mailing Address - Phone:810-599-2129
Mailing Address - Fax:
Practice Address - Street 1:2890 CARPENTER RD STE 1100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1190
Practice Address - Country:US
Practice Address - Phone:734-292-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012745247200000X
MI7401001128103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other