Provider Demographics
NPI:1780155143
Name:PEREZ, AMANDA VICTORIA (LMHC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:VICTORIA
Last Name:PEREZ
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 E MOODY BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-7706
Mailing Address - Country:US
Mailing Address - Phone:386-237-8837
Mailing Address - Fax:
Practice Address - Street 1:4721 E MOODY BLVD STE 204
Practice Address - Street 2:
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-7706
Practice Address - Country:US
Practice Address - Phone:386-237-8837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15154101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health