=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043732720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA STREET LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2017
-----------------------------------------------------
Last Update Date | 07/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12265 JAMES ST
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49424-8613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-393-5682
-----------------------------------------------------
Fax | 616-393-5682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 E CASS ST
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49013-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-450-7466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 6801101351
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------