Provider Demographics
NPI:1386951853
Name:LOPEZ, AMANDA LEE (PHD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S CRAPO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2941
Mailing Address - Country:US
Mailing Address - Phone:989-772-5938
Mailing Address - Fax:989-775-7701
Practice Address - Street 1:301 S CRAPO ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2941
Practice Address - Country:US
Practice Address - Phone:989-772-5938
Practice Address - Fax:989-775-7701
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014934103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical