Healthcare Provider Details

I. General information

NPI: 1497150676
Provider Name (Legal Business Name): AMANDA TANDY ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 LAUREL LN
STREETSBORO OH
44241-5892
US

IV. Provider business mailing address

2141 LAUREL LN
STREETSBORO OH
44241-5892
US

V. Phone/Fax

Practice location:
  • Phone: 330-577-3149
  • Fax:
Mailing address:
  • Phone: 330-577-3149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH1285747
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: