Provider Demographics
NPI:1689029290
Name:KLINGENSMITH, AMANDA JO (PHD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:KLINGENSMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:KOEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:409 PLYMOUTH RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1842
Mailing Address - Country:US
Mailing Address - Phone:734-416-9098
Mailing Address - Fax:
Practice Address - Street 1:409 PLYMOUTH RD STE 250
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1842
Practice Address - Country:US
Practice Address - Phone:734-416-9098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI6301017379103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program