Provider Demographics
NPI:1841765021
Name:AMISI, SOYAPONGA PROVIDENCE II
Entity Type:Individual
Prefix:
First Name:SOYAPONGA
Middle Name:PROVIDENCE
Last Name:AMISI
Suffix:II
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 1:5068 RUM CREEK CT SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5280
Mailing Address - Country:US
Mailing Address - Phone:616-690-9731
Mailing Address - Fax:
Practice Address - Street 1:2460 BURTON ST SE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-4800
Practice Address - Country:US
Practice Address - Phone:616-278-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst