Provider Demographics
NPI:1538337209
Name:EVELETH, AMANDA SUSAN (LMSW, BCBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUSAN
Last Name:EVELETH
Suffix:
Gender:F
Credentials:LMSW, BCBA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:SUSAN
Other - Last Name:MCPHERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:375 APPLE TREE DR
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-7506
Mailing Address - Country:US
Mailing Address - Phone:616-527-1790
Mailing Address - Fax:616-527-0538
Practice Address - Street 1:375 APPLE TREE DR
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846
Practice Address - Country:US
Practice Address - Phone:616-527-1790
Practice Address - Fax:616-527-0538
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091244104100000X
MI7401000217103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1715928Medicaid