Provider Demographics
NPI:1164284881
Name:LONG, AMANDA (IMH 21909)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:IMH 21909
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9999 CHEMSTRAND RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-2724
Mailing Address - Country:US
Mailing Address - Phone:850-471-3430
Mailing Address - Fax:
Practice Address - Street 1:9999 CHEMSTRAND RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-2724
Practice Address - Country:US
Practice Address - Phone:850-471-3430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23636101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health