Basic Information
| Provider Information | |||||||||
| NPI: | 1508318429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIMON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LIMON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LLMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 632 N SHIAWASSEE ST | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488672232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897230330 | ||||||||
| FaxNumber: | 5176765460 | ||||||||
| Practice Location | |||||||||
| Address1: | 632 N SHIAWASSEE ST | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897230330 | ||||||||
| FaxNumber: | 5176765460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2016 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801098530 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1462371 | 05 | MI | MEDICAID | 0P26570 | 01 | MI | MEDICARE PTAN | OTHER |