Healthcare Provider Details

I. General information

NPI: 1033635529
Provider Name (Legal Business Name): AMANDA ROZENA DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 08/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BURLINGTON RD STE 240
JACKSON OH
45640-9360
US

IV. Provider business mailing address

3086 STATE ROUTE 160
GALLIPOLIS OH
45631-8409
US

V. Phone/Fax

Practice location:
  • Phone: 740-286-5075
  • Fax: 740-395-8411
Mailing address:
  • Phone: 740-446-5500
  • Fax: 740-446-2159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberAPP-000074679
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: