Provider Demographics
NPI:1609447499
Name:JUSTICE, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:LAKEMORE
Mailing Address - State:OH
Mailing Address - Zip Code:44250-0163
Mailing Address - Country:US
Mailing Address - Phone:330-802-1010
Mailing Address - Fax:
Practice Address - Street 1:18660 BAGLEY RD STE 404
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3483
Practice Address - Country:US
Practice Address - Phone:440-234-8746
Practice Address - Fax:440-234-8748
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.5065103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist