Healthcare Provider Details

I. General information

NPI: 1679086664
Provider Name (Legal Business Name): AMANDA GREGORY LSW, LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 SILVER BRIDGE PLZ
GALLIPOLIS OH
45631
US

IV. Provider business mailing address

PO BOX 390
HUNTINGTON WV
25708-0390
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-4600
  • Fax:
Mailing address:
  • Phone: 304-429-1088
  • Fax: 304-429-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.161418
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: