Provider Demographics
NPI:1356840714
Name:RISALITI, AMANDA D (CDCA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:D
Last Name:RISALITI
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2058
Mailing Address - Country:US
Mailing Address - Phone:330-343-6631
Mailing Address - Fax:330-343-8188
Practice Address - Street 1:331 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615-1347
Practice Address - Country:US
Practice Address - Phone:330-627-4313
Practice Address - Fax:330-343-8188
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA165979101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)