Provider Demographics
NPI:1588621288
Name:WHITLEY, AMANDA (OT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MORELOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1040 GULF BREEZE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-7808
Mailing Address - Country:US
Mailing Address - Phone:850-916-3700
Mailing Address - Fax:850-916-3710
Practice Address - Street 1:1040 GULF BREEZE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7808
Practice Address - Country:US
Practice Address - Phone:850-916-3700
Practice Address - Fax:850-916-3710
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT18370225X00000X
GAOT003606225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67BBBKCMedicare ID - Type Unspecified
GAQ20519Medicare UPIN