Provider Demographics
NPI:1043798978
Name:BELLIS, AMANDA (LMHC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BELLIS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1879 HEARTLAND DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1026
Mailing Address - Country:US
Mailing Address - Phone:270-402-5126
Mailing Address - Fax:
Practice Address - Street 1:1 11TH AVE STE C2
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1300
Practice Address - Country:US
Practice Address - Phone:850-609-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH16136101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health