Provider Demographics
NPI:1760868954
Name:BEAGLE, AMANDA DEE
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DEE
Last Name:BEAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:DEE
Other - Last Name:BUCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4376 BENNETT DR
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1112
Mailing Address - Country:US
Mailing Address - Phone:810-691-3160
Mailing Address - Fax:
Practice Address - Street 1:4376 BENNETT DR
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1112
Practice Address - Country:US
Practice Address - Phone:810-691-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1235115460101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor