Healthcare Provider Details

I. General information

NPI: 1306186812
Provider Name (Legal Business Name): AMANDA LYNN CISSE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 S ROSS ST
BEAVERTON MI
48612-9101
US

IV. Provider business mailing address

9249 W LAKE CITY RD
HOUGHTON LAKE MI
48629-9602
US

V. Phone/Fax

Practice location:
  • Phone: 989-422-5122
  • Fax:
Mailing address:
  • Phone: 989-422-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801091799
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: