Healthcare Provider Details

I. General information

NPI: 1205287661
Provider Name (Legal Business Name): AMANDA PAYNE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 01/10/2021
Certification Date: 01/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 PASEO REYES DR
SAINT AUGUSTINE FL
32095-8462
US

IV. Provider business mailing address

264 PASEO REYES DR
SAINT AUGUSTINE FL
32095-8462
US

V. Phone/Fax

Practice location:
  • Phone: 904-481-9131
  • Fax: 904-562-3465
Mailing address:
  • Phone: 904-481-9131
  • Fax: 904-562-3465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13243
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: