Healthcare Provider Details

I. General information

NPI: 1902227721
Provider Name (Legal Business Name): AMANDA RIVAS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 WATERMAN ST
DETROIT MI
48209-2022
US

IV. Provider business mailing address

1700 WATERMAN ST
DETROIT MI
48209-2022
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094972
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: