Provider Demographics
NPI:1679055727
Name:DUNSTAN, AMIE JENNIFER
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:JENNIFER
Last Name:DUNSTAN
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 1:6333 MURRAY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:246 NORTHLAND DR STE 200A
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3440
Practice Address - Country:US
Practice Address - Phone:330-725-9195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.170864101YA0400X
OHS.19036461041C0700X
171M00000X
OHI.22033531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0312261Medicaid