Provider Demographics
NPI:1376074401
Name:ALEX, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ALEX
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 1:2123 FLUORSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10722 STANDING STONE DR
Practice Address - Street 2:
Practice Address - City:WIMAUMA
Practice Address - State:FL
Practice Address - Zip Code:33598-6163
Practice Address - Country:US
Practice Address - Phone:813-922-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL663054Medicaid