Provider Demographics
NPI:1497000343
Name:FAVA, AMANDA M (LISW-S)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:FAVA
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:554 W CENTRAL AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1499
Mailing Address - Country:US
Mailing Address - Phone:740-498-0148
Mailing Address - Fax:
Practice Address - Street 1:554 W CENTRAL AVE STE 2
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1499
Practice Address - Country:US
Practice Address - Phone:740-498-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.2304464104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker