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General NPI Number Information
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NPI Number | 1023724127
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Entity Type | Individual
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Provider Name | AMANDA FACKLER LPC
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Gender | Female
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Dates
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Enumeration Date | 01/24/2023
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Last Update Date | 01/20/2025
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Provider Practice Location Address
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Address Line | 8480 N 32ND ST UNIT 92
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City | RICHLAND
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State | MI
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Zip | 49083-9817
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Country | US
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Telephone | 269-215-5753
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Fax |
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Provider Business Mailing Address
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Address Line | 5228 LOVERS LN STE 102
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City | PORTAGE
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State | MI
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Zip | 49002-1521
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Country | US
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Telephone | 810-837-2046
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6451022560
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401224616
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License Number State | MI
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