Provider Demographics
NPI:1710543269
Name:STOUT, AMANDA LYNN (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:STOUT
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYNN
Other - Last Name:LUURTSEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:5340 PLYMOUTH ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105
Mailing Address - Country:US
Mailing Address - Phone:734-883-4218
Mailing Address - Fax:
Practice Address - Street 1:5340 PLYMOUTH ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105
Practice Address - Country:US
Practice Address - Phone:734-462-3210
Practice Address - Fax:734-369-6084
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011042951041C0700X
MI68011163991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801104295OtherPRIVATE PRACTICE
MI6801104295Medicaid