Provider Demographics
NPI:1205050747
Name:AMATO, LISA SELVIG (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SELVIG
Last Name:AMATO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 BLUE HERON LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2562
Mailing Address - Country:US
Mailing Address - Phone:904-270-0743
Mailing Address - Fax:
Practice Address - Street 1:1538 THE GREENS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-2499
Practice Address - Country:US
Practice Address - Phone:904-543-0161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6944103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent