1871000315 NPI number — MS. AMY BETH CLOSE LSW, LCDC III

Table of content: MS. AMY BETH CLOSE LSW, LCDC III (NPI 1871000315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871000315 NPI number — MS. AMY BETH CLOSE LSW, LCDC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOSE
Provider First Name:
AMY
Provider Middle Name:
BETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LSW, LCDC III
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871000315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2775 STATE ROUTE 39
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44875-9466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-747-0826
Provider Business Mailing Address Fax Number:
419-747-3504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2775 STATE ROUTE 39
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44875-9466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-747-0826
Provider Business Practice Location Address Fax Number:
419-747-3504
Provider Enumeration Date:
01/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  S.1201138 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: LCDCIII.131182 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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