Provider Demographics
NPI:1710212857
Name:KANTARAS, AMANDA L (LPCC-S)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:KANTARAS
Suffix:
Gender:F
Credentials:LPCC-S
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:535 MARMION AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44502-2323
Mailing Address - Country:US
Mailing Address - Phone:330-782-5664
Mailing Address - Fax:330-782-1614
Practice Address - Street 1:535 MARMION AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-2323
Practice Address - Country:US
Practice Address - Phone:330-782-5664
Practice Address - Fax:330-782-1614
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.131240101YA0400X
OHE.0900345-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0160195Medicaid