Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 6301015167 | MI |
Y | 103G00000X | Clinical Psychologist | 6301015167 | MI |
Y | 103TC0700X | Clinical Psychologist | 6301015167 | MI |
NPI | 1295099257 |
---|---|
Provider Name | Amanda Matthews |
First Address | Hastings, MI 49058-9018 |
Second Address | Hastings, MI 49058-9018 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2012 |
Last Update Date | 20/07/2017 |