Healthcare Provider Details

I. General information

NPI: 1154640522
Provider Name (Legal Business Name): AMANDA SONG HEE VANDENBUSCH MA, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 05/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 E WEST MAPLE RD SUITE D-407
COMMERCE TOWNSHIP MI
48390-3801
US

IV. Provider business mailing address

114 ORCHARD LAKE RD
PONTIAC MI
48341-2244
US

V. Phone/Fax

Practice location:
  • Phone: 248-624-3811
  • Fax: 248-624-0368
Mailing address:
  • Phone: 248-858-7766
  • Fax: 248-858-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011593
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: