Basic Information
| Provider Information | |||||||||
| NPI: | 1033469721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTENBERG | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MFT-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 E BAGLEY RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440172058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402608300 | ||||||||
| FaxNumber: | 4402608305 | ||||||||
| Practice Location | |||||||||
| Address1: | 195 N GRANT AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432152855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885229174 | ||||||||
| FaxNumber: | 6149289092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2012 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ICDC.161006 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | M0900021 | OK | N | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | F1300004-SUPV | OH | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.