Provider Demographics
NPI:1497000343
Name:FAVA, AMANDA M (LISW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:FAVA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:71 E WILSON BRIDGE RD STE A5
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-2358
Mailing Address - Country:US
Mailing Address - Phone:419-577-1246
Mailing Address - Fax:
Practice Address - Street 1:71 E WILSON BRIDGE RD STE A5
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2358
Practice Address - Country:US
Practice Address - Phone:614-547-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2304464104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker