Provider Demographics
NPI:1609501857
Name:WILSON-BLEVENS, AMANDA VICTORIA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:VICTORIA
Last Name:WILSON-BLEVENS
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 1:6780 MAYFIELD RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2203
Mailing Address - Country:US
Mailing Address - Phone:440-312-4500
Mailing Address - Fax:
Practice Address - Street 1:3737 LANDER RD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5712
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-21
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000583439104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker