Basic Information
Provider Information | |||||||||
NPI: | 1063886588 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASE | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | LEDYARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISW-S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEDYARD | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LISW-S | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 204 COOK RD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | LEBANON | ||||||||
State: | OH | ||||||||
PostalCode: | 450369600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5132287800 | ||||||||
FaxNumber: | 5137252231 | ||||||||
Practice Location | |||||||||
Address1: | 375 DIXMYTH AVE | ||||||||
Address2: |   | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452202475 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138531300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2015 | ||||||||
LastUpdateDate: | 08/25/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1800820-SUPV | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 2565399 | 05 | OH |   | MEDICAID | 0262920 | 05 | OH |   | MEDICAID |