Healthcare Provider Details

I. General information

NPI: 1982978565
Provider Name (Legal Business Name): AMANDA WOODMAN SWARTZLENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2012
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 MARKET ST
ST AUGUSTINE FL
32095-8892
US

IV. Provider business mailing address

631 MCKENZIE OAK LN
ST AUGUSTINE FL
32095-6861
US

V. Phone/Fax

Practice location:
  • Phone: 808-258-8089
  • Fax: 904-687-0551
Mailing address:
  • Phone: 808-258-8089
  • Fax: 904-940-6982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH9369
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12109
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: