1710543269 NPI number — MRS. AMANDA LYNN STOUT LLMSW

Table of content: MRS. AMANDA LYNN STOUT LLMSW (NPI 1710543269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710543269 NPI number — MRS. AMANDA LYNN STOUT LLMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOUT
Provider First Name:
AMANDA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LLMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUURTSEMA
Provider Other First Name:
AMANDA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710543269
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5340 PLYMOUTH ROAD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-883-4218
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5340 PLYMOUTH ROAD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-462-3210
Provider Business Practice Location Address Fax Number:
734-369-6084
Provider Enumeration Date:
05/09/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801104295 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6801116399 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6801104295 . This is a "PRIVATE PRACTICE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6801104295 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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