Provider Demographics
NPI:1487386157
Name:EUBANKS, AMANDA KAY
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:EUBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KAY
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 S WEST ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2570
Mailing Address - Country:US
Mailing Address - Phone:810-895-1351
Mailing Address - Fax:
Practice Address - Street 1:14930 LAPLAISANCE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3880
Practice Address - Country:US
Practice Address - Phone:734-344-5269
Practice Address - Fax:734-430-8188
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI81-2060761Medicaid