Basic Information
| Provider Information | |||||||||
| NPI: | 1033539713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HONZO | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | JEANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BCABA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148327577 | ||||||||
| FaxNumber: | 6144368704 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148327577 | ||||||||
| FaxNumber: | 6144368704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2014 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | OH | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.