Healthcare Provider Details

I. General information

NPI: 1043793037
Provider Name (Legal Business Name): AMANDA B MOWRY LCDCII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 E CAMPUS VIEW BLVD
COLUMBUS OH
43235-4634
US

IV. Provider business mailing address

649 RANDOLPH CT
WORTHINGTON OH
43085-5833
US

V. Phone/Fax

Practice location:
  • Phone: 614-505-3126
  • Fax:
Mailing address:
  • Phone: 614-531-1262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.161950
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33.023903
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: