Provider Demographics
NPI:1609219773
Name:SMITH, AMY JO
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:RUNYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:8148 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:45710-8847
Mailing Address - Country:US
Mailing Address - Phone:740-590-8717
Mailing Address - Fax:
Practice Address - Street 1:11 GRAHAM DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1430
Practice Address - Country:US
Practice Address - Phone:740-594-6807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS10002291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical