Provider Demographics
NPI:1578234746
Name:LORD, AMANDA JEANETTE (AS, CDCA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEANETTE
Last Name:LORD
Suffix:
Gender:
Credentials:AS, CDCA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEANETTE
Other - Last Name:GORDLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:602 S SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2791
Mailing Address - Country:US
Mailing Address - Phone:937-414-2016
Mailing Address - Fax:
Practice Address - Street 1:602 S SOUTH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2791
Practice Address - Country:US
Practice Address - Phone:937-414-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.178529101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator