Healthcare Provider Details

I. General information

NPI: 1780076356
Provider Name (Legal Business Name): AMANDA GORDON CACIII
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 S BELCHER RD
CLEARWATER FL
33764-2829
US

IV. Provider business mailing address

1004 CARBON
TRINIDAD CO
81082-3664
US

V. Phone/Fax

Practice location:
  • Phone: 727-524-4464
  • Fax: 727-538-7272
Mailing address:
  • Phone: 719-846-4481
  • Fax: 719-846-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6848
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: