Provider Demographics
NPI:1427763465
Name:PRADNA-WAUGAMAN, AMY (LPC, LLMFT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PRADNA-WAUGAMAN
Suffix:
Gender:
Credentials:LPC, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 NEWPORT RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9234
Mailing Address - Country:US
Mailing Address - Phone:269-409-3000
Mailing Address - Fax:269-366-4004
Practice Address - Street 1:6070 NEWPORT RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9234
Practice Address - Country:US
Practice Address - Phone:269-409-3000
Practice Address - Fax:269-366-4004
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4151001086106H00000X
MI6401225130101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist