Basic Information
Provider Information | |||||||||
NPI: | 1396932414 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONGWORTH | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | LISW-S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSON | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LISW-S | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2000 NOBLE DR | ||||||||
Address2: |   | ||||||||
City: | WOOSTER | ||||||||
State: | OH | ||||||||
PostalCode: | 446915353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302643232 | ||||||||
FaxNumber: | 3302023879 | ||||||||
Practice Location | |||||||||
Address1: | 2803 AKRON RD | ||||||||
Address2: |   | ||||||||
City: | WOOSTER | ||||||||
State: | OH | ||||||||
PostalCode: | 44691 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302643232 | ||||||||
FaxNumber: | 3302023879 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2007 | ||||||||
LastUpdateDate: | 08/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I1600249-SUPV | OH | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.