Provider Demographics
NPI:1053603225
Name:PRUNEAU, AMY KATHLEEN (LLP)
Entity type:Individual
Prefix:MISS
First Name:AMY
Middle Name:KATHLEEN
Last Name:PRUNEAU
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 NEPTUNE DR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3661
Mailing Address - Country:US
Mailing Address - Phone:248-821-6485
Mailing Address - Fax:
Practice Address - Street 1:260 NEPTUNE DR
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3661
Practice Address - Country:US
Practice Address - Phone:248-821-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014003103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent