Provider Demographics
NPI:1629676259
Name:ANDERSON, AMY MICHELLE
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:MICHELLE
Last Name:ANDERSON
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 1:233 SW WILSON AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2988
Mailing Address - Country:US
Mailing Address - Phone:541-382-8862
Mailing Address - Fax:
Practice Address - Street 1:233 SW WILSON AVE, STE 201
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-382-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1225169378Medicaid
OR1225169378OtherOHP