Healthcare Provider Details

I. General information

NPI: 1689408999
Provider Name (Legal Business Name): AMANDA KACZMAREK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 W MAUMEE ST APT 1
ADRIAN MI
49221-2094
US

IV. Provider business mailing address

627 W MAUMEE ST APT 1
ADRIAN MI
49221-2094
US

V. Phone/Fax

Practice location:
  • Phone: 419-351-6659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451025140
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: