Provider Demographics
NPI:1043525041
Name:BRACE, AMANDA KATHLEEN (LPCC-S, MED)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:BRACE
Suffix:
Gender:F
Credentials:LPCC-S, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-3440
Mailing Address - Country:US
Mailing Address - Phone:440-361-0127
Mailing Address - Fax:330-548-0039
Practice Address - Street 1:2334 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-3440
Practice Address - Country:US
Practice Address - Phone:440-361-0127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1485147101YS0200X
OHE.0900428-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool