Basic Information
| Provider Information | |||||||||
| NPI: | 1346983459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FENN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | KIMBERLY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURBANK | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | KIMBERLY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8576 JASONVILLE CT SE | ||||||||
| Address2: | |||||||||
| City: | CALEDONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493168287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478589889 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1560 LEONARD ST NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164607647 | ||||||||
| FaxNumber: | 6164585430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2022 | ||||||||
| LastUpdateDate: | 04/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.