Provider Demographics
NPI:1841608262
Name:PENDLETON, AMY LEE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LEE
Last Name:PENDLETON
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 1:521 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-1301
Mailing Address - Country:US
Mailing Address - Phone:386-496-9604
Mailing Address - Fax:
Practice Address - Street 1:521 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:LAKE BUTLER
Practice Address - State:FL
Practice Address - Zip Code:32054-1301
Practice Address - Country:US
Practice Address - Phone:386-496-9604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL230596103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst