Provider Demographics
NPI:1134761422
Name:AMENDOLACE, BLAISE (PSYD)
Entity type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:
Last Name:AMENDOLACE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9780 NW 5TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-6817
Mailing Address - Country:US
Mailing Address - Phone:321-243-8218
Mailing Address - Fax:
Practice Address - Street 1:9780 NW 5TH CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-6817
Practice Address - Country:US
Practice Address - Phone:321-243-8218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8603103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist