Healthcare Provider Details

I. General information

NPI: 1891284717
Provider Name (Legal Business Name): AMANDA MARIE JOHNSON LCDCII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 E 3RD ST
DAYTON OH
45403-1850
US

IV. Provider business mailing address

1899 LOWER BELLBROOK RD
XENIA OH
45385-9310
US

V. Phone/Fax

Practice location:
  • Phone: 937-387-6395
  • Fax:
Mailing address:
  • Phone: 937-613-9537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2506279
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberLCDCII.161326
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: