Provider Demographics
NPI:1568684223
Name:PETTIS, AMBER (MS)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PETTIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16023 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-2861
Mailing Address - Country:US
Mailing Address - Phone:954-661-6454
Mailing Address - Fax:
Practice Address - Street 1:16023 MUIRFIELD DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-2861
Practice Address - Country:US
Practice Address - Phone:954-661-6454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9884101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health