MEDICARE: AMANDA ELIZABETH REISTER LLC

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	101YM0800X	Mental Health Counselor	6451022481	MI

General Provider Information

NPI Number	:	1811619091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ELIZABETH REISTER LLC

Provider Business Mailing Address
First Line	:	2801 MASEFIELD DR
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48304-1948
Country	:	US
Telephone Number	:	346-346-6145
Fax Number	:

Provider Business Practice Location Address
First Line	:	2242 S TELEGRAPH RD STE 209
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-0218
Country	:	US
Telephone Number	:	248-346-6145
Fax Number	:

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

Provider Enumeration Date	:	09/14/2022
Last Update Date	:	09/14/2022

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