Provider Demographics
NPI:1417326141
Name:PARKS, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PARKS
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 1:514 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:FL
Mailing Address - Zip Code:32052-6188
Mailing Address - Country:US
Mailing Address - Phone:386-855-4628
Mailing Address - Fax:
Practice Address - Street 1:514 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:FL
Practice Address - Zip Code:32052-6188
Practice Address - Country:US
Practice Address - Phone:386-855-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist