=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104791003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MARIE PHIPPS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2025
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 231 LAFAYETTE ST STE E
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-8567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-901-0844
-----------------------------------------------------
Fax | 614-792-6240
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 1/2 E HIGH ST
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-981-1677
-----------------------------------------------------
Fax | 614-792-6240
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CDCA.193923
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------