Provider Demographics
NPI:1215484183
Name:KELLEY, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 CLENEAY AVE APT 1303
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3666
Mailing Address - Country:US
Mailing Address - Phone:214-773-6405
Mailing Address - Fax:
Practice Address - Street 1:4721 READING RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45237-6107
Practice Address - Country:US
Practice Address - Phone:513-482-7271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health