Healthcare Provider Details

I. General information

NPI: 1649849605
Provider Name (Legal Business Name): AMY WELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 EDALBERT DR
CINCINNATI OH
45239-7604
US

IV. Provider business mailing address

719 FOUNTAIN ABBEY PL
MIAMISBURG OH
45342-2726
US

V. Phone/Fax

Practice location:
  • Phone: 855-577-7284
  • Fax:
Mailing address:
  • Phone: 937-776-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.2204690
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC2103316-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: