MEDICARE: AMANDA KATHLEEN BRACE LPCC-S, M.ED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor	OH1485147	OH
2	101YP2500X	Professional Counselor	E.0900428-SUPV	OH

General Provider Information

NPI Number	:	1043525041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA KATHLEEN BRACE LPCC-S, M.ED

Provider Business Mailing Address
First Line	:	2334 LAKE AVE
Second Line	:
City	:	ASHTABULA
State	:	OH
Zip	:	44004-3440
Country	:	US
Telephone Number	:	440-361-0127
Fax Number	:	330-548-0039

Provider Business Practice Location Address
First Line	:	2334 LAKE AVE
Second Line	:
City	:	ASHTABULA
State	:	OH
Zip	:	44004-3440
Country	:	US
Telephone Number	:	440-361-0127
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	07/11/2022

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