MEDICARE: AMANDA JO ADAMS LISW-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	I. 0600081 SUPV	OH

General Provider Information

NPI Number	:	1003146564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JO ADAMS LISW-S

Provider Business Mailing Address
First Line	:	4419 DEEDS RD SW
Second Line	:
City	:	PATASKALA
State	:	OH
Zip	:	43062-7447
Country	:	US
Telephone Number	:	740-404-1339
Fax Number	:

Provider Business Practice Location Address
First Line	:	905 RIVER RD STE A
Second Line	:
City	:	GRANVILLE
State	:	OH
Zip	:	43023-9560
Country	:	US
Telephone Number	:	740-587-2822
Fax Number	:	740-587-2822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2010
Last Update Date	:	01/06/2010

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