Provider Demographics
NPI:1861959181
Name:CALLAHAN, AMANDA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 HERRICK AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5311
Mailing Address - Country:US
Mailing Address - Phone:734-474-0188
Mailing Address - Fax:
Practice Address - Street 1:2378 WOODLAKE DR STE 280
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6016
Practice Address - Country:US
Practice Address - Phone:517-706-0421
Practice Address - Fax:517-706-0423
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006133235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist