Provider Demographics
NPI:1467465609
Name:AMIGO, EMILIO M (PSY D)
Entity Type:Individual
Prefix:DR
First Name:EMILIO
Middle Name:M
Last Name:AMIGO
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E. CAMPUS VIEW BLVD.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-5971
Mailing Address - Country:US
Mailing Address - Phone:614-310-1234
Mailing Address - Fax:614-310-1237
Practice Address - Street 1:355 E. CAMPUS VIEW BLVD.
Practice Address - Street 2:SUITE 105
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-5971
Practice Address - Country:US
Practice Address - Phone:614-310-1234
Practice Address - Fax:614-310-1237
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4585103TB0200X, 103TC1900X, 103TC2200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAMCP12284Medicare PIN