Healthcare Provider Details

I. General information

NPI: 1861847089
Provider Name (Legal Business Name): AMANDA MARTIN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARTIN LMSW

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801099505
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: