Provider Demographics
NPI:1972085082
Name:BEVAN, AMANDA DANIELLE (LISW)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELLE
Last Name:BEVAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DANIELLE
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2249 WINDSOR CHASE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-8913
Mailing Address - Country:US
Mailing Address - Phone:740-610-4023
Mailing Address - Fax:
Practice Address - Street 1:1120 POLARIS PKWY STE 204
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-4042
Practice Address - Country:US
Practice Address - Phone:614-356-8565
Practice Address - Fax:614-559-9758
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2203923104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI.2203923OtherLISW