Provider Demographics
NPI:1619331824
Name:FLANNERY, AMANDA HEATHER (MED, LPC, LICDC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:HEATHER
Last Name:FLANNERY
Suffix:
Gender:F
Credentials:MED, LPC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2815
Mailing Address - Country:US
Mailing Address - Phone:937-376-8700
Mailing Address - Fax:937-376-8725
Practice Address - Street 1:452 W MARKET ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2815
Practice Address - Country:US
Practice Address - Phone:937-376-8700
Practice Address - Fax:937-376-8725
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1600051101YM0800X
OH140760101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222303Medicaid
OH137Medicaid