Provider Demographics
NPI:1962822577
Name:DIVIS, AMANDA (LISW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DIVIS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:3950 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-4625
Mailing Address - Country:US
Mailing Address - Phone:216-431-4131
Mailing Address - Fax:216-431-4151
Practice Address - Street 1:3950 CHESTER AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-4625
Practice Address - Country:US
Practice Address - Phone:216-431-4131
Practice Address - Fax:216-431-4151
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI15012411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical