Provider Demographics
NPI:1427340249
Name:REAGAN, AMANDA RAYBURN (LCSW-S, LISW-S)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAYBURN
Last Name:REAGAN
Suffix:
Gender:F
Credentials:LCSW-S, LISW-S
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:RAYBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 JERRY DR
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-6222
Mailing Address - Country:US
Mailing Address - Phone:713-876-7990
Mailing Address - Fax:
Practice Address - Street 1:8170 JERRY DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-6222
Practice Address - Country:US
Practice Address - Phone:713-876-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX514871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282721401OtherTPI
TXTXB130597Medicare PIN