Healthcare Provider Details

I. General information

NPI: 1609292713
Provider Name (Legal Business Name): AMANDA LARSON M.A., MLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA WILLIS MA., LLP

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 WEALTHY ST SE STE 256
GRAND RAPIDS MI
49506-2755
US

IV. Provider business mailing address

1514 WEALTHY ST SE STE 256
GRAND RAPIDS MI
49506-2755
US

V. Phone/Fax

Practice location:
  • Phone: 616-780-1284
  • Fax: 616-427-1624
Mailing address:
  • Phone: 616-780-1284
  • Fax: 616-427-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301015820
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: