Healthcare Provider Details

I. General information

NPI: 1275328882
Provider Name (Legal Business Name): AMANDA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 W LONG ST
COLUMBUS OH
43215-2815
US

IV. Provider business mailing address

16 W LONG ST
COLUMBUS OH
43215-2815
US

V. Phone/Fax

Practice location:
  • Phone: 614-225-0990
  • Fax: 614-225-0991
Mailing address:
  • Phone: 614-225-0990
  • Fax: 614-225-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCDCA195913
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS005771
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: