Basic Information
| Provider Information | |||||||||
| NPI: | 1306379466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUKASCHEWSKI | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 ROBERT T LONGWAY BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104964955 | ||||||||
| FaxNumber: | 8103213002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 ROBERT T LONGWAY BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104964955 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2017 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-18-30628 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | RBT-15-06363 | MI | N |
No ID Information.