Healthcare Provider Details

I. General information

NPI: 1164393419
Provider Name (Legal Business Name): MS. AMANDA RAE HORTON I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N MCVICAR ST
ADRIAN MI
49221-3056
US

IV. Provider business mailing address

1424 S MAIN ST STE 2
ADRIAN MI
49221-4309
US

V. Phone/Fax

Practice location:
  • Phone: 517-312-1711
  • Fax: 517-313-1711
Mailing address:
  • Phone: 517-312-1711
  • Fax: 517-313-1711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberH635066730822
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: