Provider Demographics
NPI:1891920021
Name:MARTIN, AMANDA MICHELLE (PCC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3903
Mailing Address - Country:US
Mailing Address - Phone:740-687-0042
Mailing Address - Fax:740-687-6677
Practice Address - Street 1:624 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3903
Practice Address - Country:US
Practice Address - Phone:740-687-0042
Practice Address - Fax:740-687-6677
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0500756101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional