Provider Demographics
NPI:1770604522
Name:SMITH, AMANDA STEPHENIE (PSYD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:STEPHENIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:STEPHENIE
Other - Last Name:CASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-0903
Mailing Address - Country:US
Mailing Address - Phone:517-677-3339
Mailing Address - Fax:
Practice Address - Street 1:28 W CHICAGO ST
Practice Address - Street 2:STE 3A
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1677
Practice Address - Country:US
Practice Address - Phone:517-677-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013433103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical