Provider Demographics
NPI:1396370011
Name:NEWSOME, AMANDA LYNN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:NEWSOME
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 1:40 STATE HIGHWAY 83
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-7404
Mailing Address - Country:US
Mailing Address - Phone:850-585-9189
Mailing Address - Fax:850-951-0898
Practice Address - Street 1:40 STATE HIGHWAY 83
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-7404
Practice Address - Country:US
Practice Address - Phone:850-585-9189
Practice Address - Fax:850-951-0898
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-112588106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty