Healthcare Provider Details

I. General information

NPI: 1871000315
Provider Name (Legal Business Name): AMY BETH CLOSE LSW, LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

IV. Provider business mailing address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

V. Phone/Fax

Practice location:
  • Phone: 419-747-0826
  • Fax: 419-747-3504
Mailing address:
  • Phone: 419-747-0826
  • Fax: 419-747-3504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.131182
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberS.1201138
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: