Provider Demographics
NPI:1033469721
Name:WATTENBERG, AMANDA M (MFT-S)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:WATTENBERG
Suffix:
Gender:F
Credentials:MFT-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-2058
Mailing Address - Country:US
Mailing Address - Phone:440-260-8300
Mailing Address - Fax:440-260-8305
Practice Address - Street 1:195 N GRANT AVE STE 250
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2855
Practice Address - Country:US
Practice Address - Phone:888-522-9174
Practice Address - Fax:614-928-9092
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHICDC.161006101YA0400X
OKM0900021101YP2500X
OHF1300004-SUPV106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional