Provider Demographics
NPI:1043705320
Name:CHILCOTT, AMANDA LEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:CHILCOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 ROOSEVELT BLVD APT 4453
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33760-2599
Mailing Address - Country:US
Mailing Address - Phone:814-528-1492
Mailing Address - Fax:
Practice Address - Street 1:1001 E BAKER ST STE 100
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3700
Practice Address - Country:US
Practice Address - Phone:813-754-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health