Provider Demographics
NPI:1245720424
Name:ALLEN, AMANDA ANN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:ALLEN
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 1:5104 W GARBOW RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49333-8231
Mailing Address - Country:US
Mailing Address - Phone:269-509-2807
Mailing Address - Fax:
Practice Address - Street 1:165 SORRENTO DRIVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-970-4172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician