Healthcare Provider Details

I. General information

NPI: 1669113403
Provider Name (Legal Business Name): AMANDA M SEABOLT PH.D., PMHNP-BC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 MAIN ST
SYLVANIA OH
43560-2184
US

IV. Provider business mailing address

5151 MAIN ST
SYLVANIA OH
43560-2184
US

V. Phone/Fax

Practice location:
  • Phone: 419-266-0072
  • Fax: 419-754-2306
Mailing address:
  • Phone: 419-266-0072
  • Fax: 419-754-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN.393970
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0038240
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704419865
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: