Healthcare Provider Details

I. General information

NPI: 1245672146
Provider Name (Legal Business Name): AMANDA DAWN SMALLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 E 5TH AVE
COLUMBUS OH
43219-2806
US

IV. Provider business mailing address

3210 E 5TH AVE
COLUMBUS OH
43219-2806
US

V. Phone/Fax

Practice location:
  • Phone: 614-886-4818
  • Fax:
Mailing address:
  • Phone: 614-886-4818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberRW562602
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: