Provider Demographics
NPI:1679086664
Name:GREGORY, AMANDA (LSW, LCDC III)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LSW, LCDC III
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 390
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0390
Mailing Address - Country:US
Mailing Address - Phone:304-429-1088
Mailing Address - Fax:304-429-3109
Practice Address - Street 1:420 SILVER BRIDGE PLZ
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631
Practice Address - Country:US
Practice Address - Phone:740-446-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)