Provider Demographics
NPI:1376359935
Name:FORDECK, AMELIA JANE (LSW CSW)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:JANE
Last Name:FORDECK
Suffix:
Gender:F
Credentials:LSW CSW
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:JANE
Other - Last Name:BOSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3351 MOUNT SOLOMON RD NW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-6668
Mailing Address - Country:US
Mailing Address - Phone:413-364-6911
Mailing Address - Fax:
Practice Address - Street 1:8465 COLERAIN AVE STE 1146
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-3926
Practice Address - Country:US
Practice Address - Phone:413-364-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2411564101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health