Provider Demographics
NPI:1003341785
Name:SIEBOLD, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SIEBOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:LAWLESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:407-915-7729
Mailing Address - Fax:407-588-6294
Practice Address - Street 1:101 TENNESSEE WAY
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-3160
Practice Address - Country:US
Practice Address - Phone:629-255-0339
Practice Address - Fax:615-827-0363
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103K00000X
TN1418103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid