Provider Demographics
NPI:1073030276
Name:WIEGERT, AMANDA (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:WIEGERT
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 EAST SYBELIA AVENUE SUITE 380
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4615
Mailing Address - Country:US
Mailing Address - Phone:407-448-9521
Mailing Address - Fax:
Practice Address - Street 1:100 E SYBELIA AVE STE 380
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4775
Practice Address - Country:US
Practice Address - Phone:407-448-9521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty