Provider Demographics
NPI:1588182547
Name:PERKINS, AMANDA (LISW-S, LICDC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:PERKINS
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:PENDERGRAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:11611 STATE ROUTE 771
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45135-8601
Mailing Address - Country:US
Mailing Address - Phone:937-780-2221
Mailing Address - Fax:
Practice Address - Street 1:11611 STATE ROUTE 771
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:OH
Practice Address - Zip Code:45135-8601
Practice Address - Country:US
Practice Address - Phone:937-780-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161958101YA0400X
OHI.17005281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)