Healthcare Provider Details

I. General information

NPI: 1942759899
Provider Name (Legal Business Name): AMANDA EDWARDS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 TRADE CENTRE WAY STE 140
PORTAGE MI
49002-0411
US

IV. Provider business mailing address

650 TRADE CENTRE WAY STE 140
PORTAGE MI
49002-0411
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax:
Mailing address:
  • Phone: 517-882-2732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2014044331
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401224845
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: