Healthcare Provider Details

I. General information

NPI: 1003577412
Provider Name (Legal Business Name): AMANDA LYN WENDLE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CRYSTAL LAKE DR
LAKELAND FL
33801-5979
US

IV. Provider business mailing address

5006 COPPERSTONE CIR
MULBERRY FL
33860-8605
US

V. Phone/Fax

Practice location:
  • Phone: 863-709-8543
  • Fax: 863-688-2520
Mailing address:
  • Phone: 863-614-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH20141
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: