Provider Demographics
NPI:1023724127
Name:FACKLER, AMANDA (LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FACKLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5228 LOVERS LN STE 102
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1521
Mailing Address - Country:US
Mailing Address - Phone:810-837-2046
Mailing Address - Fax:
Practice Address - Street 1:8480 N 32ND ST UNIT 92
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083-9817
Practice Address - Country:US
Practice Address - Phone:269-215-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022560101YM0800X
MI6401224616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health