Provider Demographics
NPI:1720444391
Name:POISSON BUGG, AMANDA (LMSW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:POISSON BUGG
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:POISSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 776974
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6974
Mailing Address - Country:US
Mailing Address - Phone:800-494-5797
Mailing Address - Fax:
Practice Address - Street 1:300 LAFAYETTE SE
Practice Address - Street 2:STE 4000
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4692
Practice Address - Country:US
Practice Address - Phone:616-685-6922
Practice Address - Fax:616-685-5101
Is Sole Proprietor?:No
Enumeration Date:2016-01-12
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010992051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical