Provider Demographics
NPI:1639848450
Name:AMPLAA BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:AMPLAA BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SURRENCY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-300-4341
Mailing Address - Street 1:1895 KINGSLEY AVE STE 403
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4453
Mailing Address - Country:US
Mailing Address - Phone:904-300-4341
Mailing Address - Fax:
Practice Address - Street 1:1895 KINGSLEY AVE STE 403
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4453
Practice Address - Country:US
Practice Address - Phone:904-300-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-07
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty