Provider Demographics
NPI:1821288515
Name:WONG, AMANDA MICHELLE (MS)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:WONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7330 BISCAYNE WAY SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-9705
Mailing Address - Country:US
Mailing Address - Phone:616-915-5614
Mailing Address - Fax:
Practice Address - Street 1:7330 BISCAYNE WAY SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-9705
Practice Address - Country:US
Practice Address - Phone:616-915-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.000562235Z00000X
MI7101001622235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist