Provider Demographics
NPI:1730991654
Name:LEGRAND, AMANDA (MA, LLC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LEGRAND
Suffix:
Gender:F
Credentials:MA, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16828 PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2917
Mailing Address - Country:US
Mailing Address - Phone:910-581-3043
Mailing Address - Fax:
Practice Address - Street 1:18301 E 8 MILE RD STE 214
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3227
Practice Address - Country:US
Practice Address - Phone:910-581-3043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024138101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health