Provider Demographics
NPI:1912546318
Name:TRUDEAU, AMANDA MARIE
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:MARIE
Last Name:TRUDEAU
Suffix:
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 1:1100 W CAMPUS DR APT 2
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3738
Mailing Address - Country:US
Mailing Address - Phone:734-552-7248
Mailing Address - Fax:
Practice Address - Street 1:2520 UNIVERSITY PARK BLDG D
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4464
Practice Address - Country:US
Practice Address - Phone:989-774-2529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIT630066585328106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician