Healthcare Provider Details

I. General information

NPI: 1609582436
Provider Name (Legal Business Name): AMANDA HARTWIG MA, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2023
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 44TH ST SE
GRAND RAPIDS MI
49508-4633
US

IV. Provider business mailing address

708 COIT AVE NE APT 1
GRAND RAPIDS MI
49503-1508
US

V. Phone/Fax

Practice location:
  • Phone: 517-231-5607
  • Fax:
Mailing address:
  • Phone: 517-231-5607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451022742
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: