Provider Demographics
NPI:1285237107
Name:BOLAM, AMANDA LYNN (LLMSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:BOLAM
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7801 SUMMER BREEZE TRL
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9594
Mailing Address - Country:US
Mailing Address - Phone:517-375-5085
Mailing Address - Fax:
Practice Address - Street 1:120 S MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1975
Practice Address - Country:US
Practice Address - Phone:248-529-6383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011074481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty