Provider Demographics
NPI:1851893804
Name:ESTES, AMY DUSTAN (MMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DUSTAN
Last Name:ESTES
Suffix:
Gender:F
Credentials:MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 W LAKE LANSING RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-8474
Mailing Address - Country:US
Mailing Address - Phone:517-575-6362
Mailing Address - Fax:
Practice Address - Street 1:780 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8474
Practice Address - Country:US
Practice Address - Phone:517-575-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000386225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist