Provider Demographics
NPI:1447203906
Name:GHOSH, AMITA (MED)
Entity Type:Individual
Prefix:
First Name:AMITA
Middle Name:
Last Name:GHOSH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45255-4619
Mailing Address - Country:US
Mailing Address - Phone:859-391-1255
Mailing Address - Fax:
Practice Address - Street 1:1407 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-2599
Practice Address - Country:US
Practice Address - Phone:859-391-1255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1700375101YP2500X
KY103440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610661458OtherGROUP FED. TAX ID #