Provider Demographics
NPI:1114586617
Name:WILLIS, AMANDA KATHRYN
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KATHRYN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:KATHRYN
Other - Last Name:HANNUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:59 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3939
Mailing Address - Country:US
Mailing Address - Phone:740-349-7511
Mailing Address - Fax:
Practice Address - Street 1:59 GRANT ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3939
Practice Address - Country:US
Practice Address - Phone:740-349-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1904521104100000X
OHI.23043931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker