Provider Demographics
NPI:1609292713
Name:LARSON, AMANDA (MA, MLP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:MA, MLP
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LLP
Mailing Address - Street 1:1514 WEALTHY ST SE STE 256
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2755
Mailing Address - Country:US
Mailing Address - Phone:616-780-1284
Mailing Address - Fax:616-427-1624
Practice Address - Street 1:1514 WEALTHY ST SE STE 256
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2755
Practice Address - Country:US
Practice Address - Phone:616-780-1284
Practice Address - Fax:616-427-1624
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015820103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling