MEDICARE: MRS. AMANDA PETRIC 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	1041C0700X	Clinical Social Worker	I.1800880-SUPV	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	I.1800880-SUPV	OTHER	OH	CSWMFT

General Provider Information

NPI Number	:	1760863419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMANDA PETRIC LISW-S

Provider Business Mailing Address
First Line	:	250 E 5TH ST FL 15
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45202-4119
Country	:	US
Telephone Number	:	216-200-8116
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 E 5TH ST FL 15
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45202-4119
Country	:	US
Telephone Number	:	216-200-8116
Fax Number	:

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

Provider Enumeration Date	:	06/17/2015
Last Update Date	:	04/05/2024

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