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General NPI Number Information
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NPI Number | 1215537188
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Entity Type | Individual
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Provider Name | AMANDA ROSE HEREDIA BSW, LSW
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Gender | Female
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Dates
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Enumeration Date | 10/29/2020
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Last Update Date | 10/29/2020
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Provider Practice Location Address
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Address Line | 7211 TAYLORSVILLE RD STE 204
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City | HUBER HEIGHTS
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State | OH
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Zip | 45424-2377
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Country | US
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Telephone | 937-718-2739
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Fax | 937-732-6066
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Provider Business Mailing Address
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Address Line | 455 WATERVLIET AVE
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City | DAYTON
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State | OH
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Zip | 45420-2466
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Country | US
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Telephone | 937-718-2739
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | S.2005305
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License Number State | OH
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