Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 130223 | OH |
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 1500414 | OH |
NPI | 1003272220 |
---|---|
Provider Name | Amy Nelson |
First Address | Canton, OH 44714-2605 |
Second Address | Canton, OH 44714-2605 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2016 |
Last Update Date | 04/01/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2901131 | (05) | OH |