Provider Demographics
NPI:1225859143
Name:MAMAKOS, CAROLINE CHRISTIANNA
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:CHRISTIANNA
Last Name:MAMAKOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLINE
Other - Middle Name:MAMAKOS
Other - Last Name:GODFREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:315 N DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-1474
Mailing Address - Country:US
Mailing Address - Phone:305-773-3645
Mailing Address - Fax:
Practice Address - Street 1:4234 CASCADE RD SE STE 3
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8384
Practice Address - Country:US
Practice Address - Phone:877-654-4144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician