Healthcare Provider Details

I. General information

NPI: 1215351036
Provider Name (Legal Business Name): AMANDA SYVERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2110
  • Fax:
Mailing address:
  • Phone: 616-942-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0000003057
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401014031
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: