Basic Information
| Provider Information | |||||||||
| NPI: | 1669024014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVARN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 152 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PEWAMO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488738710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178819867 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3410 OLD LANSING RD | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489174392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176572980 | ||||||||
| FaxNumber: | 5179935982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2019 | ||||||||
| LastUpdateDate: | 07/15/2019 | ||||||||
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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 | 101YA0400X | 6401017471 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.