Healthcare Provider Details

I. General information

NPI: 1316774037
Provider Name (Legal Business Name): AMANDA GRAVES LLMSW
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4597
US

IV. Provider business mailing address

59 MANZANA CT NW APT 3D
GRAND RAPIDS MI
49534-5784
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-2700
  • Fax:
Mailing address:
  • Phone: 918-906-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851119317
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: