Provider Demographics
NPI:1619445376
Name:EMBRY, AMANDA LOUISE (MA, RMHCI)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LOUISE
Last Name:EMBRY
Suffix:
Gender:F
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 LAKE MIRIAM DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2180
Mailing Address - Country:US
Mailing Address - Phone:863-816-6884
Mailing Address - Fax:
Practice Address - Street 1:202 LAKE MIRIAM DR STE W6
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2179
Practice Address - Country:US
Practice Address - Phone:863-226-5081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-10
Last Update Date:2018-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty