Provider Demographics
NPI:1316785934
Name:HERRON, AMANDA LYNN
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYNN
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-0013
Mailing Address - Country:US
Mailing Address - Phone:419-262-1690
Mailing Address - Fax:
Practice Address - Street 1:3000 REGENCY CT STE 207
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3081
Practice Address - Country:US
Practice Address - Phone:419-262-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health