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General NPI Number Information
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NPI Number | 1043761349
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Entity Type | Individual
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Provider Name | AMANDA FREY M.A.
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Gender | Female
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Dates
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Enumeration Date | 10/21/2016
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Last Update Date | 07/25/2022
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Provider Practice Location Address
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Address Line | 1591 W CENTRE AVE STE 205
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City | PORTAGE
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State | MI
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Zip | 49024-6315
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Country | US
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Telephone | 269-252-4004
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Fax |
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Provider Business Mailing Address
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Address Line | 2596 CHESTNUT RIDGE AVE
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City | PORTAGE
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State | MI
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Zip | 49024-7600
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Country | US
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Telephone | 419-345-7404
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4101006707
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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 | 6401015735
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License Number State | MI
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