MEDICARE: AMANDA LEE LOPEZ PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301014934	MI

General Provider Information

NPI Number	:	1386951853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LEE LOPEZ PH.D

Provider Business Mailing Address
First Line	:	301 S CRAPO ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-2941
Country	:	US
Telephone Number	:	989-772-5938
Fax Number	:	989-775-7701

Provider Business Practice Location Address
First Line	:	301 S CRAPO ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	MI
Zip	:	48858-2941
Country	:	US
Telephone Number	:	989-772-5938
Fax Number	:	989-775-7701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2010
Last Update Date	:	12/09/2013

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