Basic Information
| Provider Information | |||||||||
| NPI: | 1881025526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EASTWOOD | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LISW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLLENBECK | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2507 W RAUCH RD | ||||||||
| Address2: | |||||||||
| City: | TEMPERANCE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481829606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193436036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 123 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192416191 | ||||||||
| FaxNumber: | 4192555623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2013 | ||||||||
| LastUpdateDate: | 05/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0700734 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 104100000X | 05 | OH | MEDICAID |