Basic Information
| Provider Information | |||||||||
| NPI: | 1568750404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOUVRETTE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE # MC845 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21175 15 MILE RD | ||||||||
| Address2: | |||||||||
| City: | BIG RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493078844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167546185 | ||||||||
| FaxNumber: | 6167546407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2011 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801093041 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.