Provider Demographics
NPI:1083197255
Name:AMENT, MARISA BROOKE
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:BROOKE
Last Name:AMENT
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 1:1883 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-4721
Mailing Address - Country:US
Mailing Address - Phone:717-869-2913
Mailing Address - Fax:
Practice Address - Street 1:1883 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-4721
Practice Address - Country:US
Practice Address - Phone:717-869-2913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist