Provider Demographics
NPI:1043793037
Name:MOWRY, AMANDA B (LCDCII)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:MOWRY
Suffix:
Gender:
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 RANDOLPH CT
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5833
Mailing Address - Country:US
Mailing Address - Phone:614-531-1262
Mailing Address - Fax:
Practice Address - Street 1:246 E CAMPUS VIEW BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4634
Practice Address - Country:US
Practice Address - Phone:614-505-3126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023903225700000X
OHLCDCII.161950101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000697Medicaid