Healthcare Provider Details

I. General information

NPI: 1063914869
Provider Name (Legal Business Name): AMANDA FORISTER MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E GRANADA BLVD STE D
ORMOND BEACH FL
32176-6694
US

IV. Provider business mailing address

319 OAK FERN CIR
ORMOND BEACH FL
32174-4875
US

V. Phone/Fax

Practice location:
  • Phone: 307-257-2331
  • Fax: 307-670-8042
Mailing address:
  • Phone: 307-363-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPPC-1056
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC1828
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberMH24302
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH24302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: