Provider Demographics
NPI:1356606115
Name:FILLBACH, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FILLBACH
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 1:2911 MEADOWBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2801
Mailing Address - Country:US
Mailing Address - Phone:216-816-8181
Mailing Address - Fax:
Practice Address - Street 1:3500 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-2641
Practice Address - Country:US
Practice Address - Phone:216-536-6712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1100256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health