=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194074567
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY BELLOWS CLARK PMHCNS-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2012
-----------------------------------------------------
Last Update Date | 05/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3909 WOODLEY RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606-1169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-725-3330
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3909 WOODLEY RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606-1169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-475-4449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | RN.205761-COA1
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 364SP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | APRN.CNS.13737
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------