Healthcare Provider Details

I. General information

NPI: 1164258547
Provider Name (Legal Business Name): AMIRA KHATIB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S DILLARD ST STE 120B
WINTER GARDEN FL
34787-3596
US

IV. Provider business mailing address

16507 LOWRY RD
MONTVERDE FL
34756-3151
US

V. Phone/Fax

Practice location:
  • Phone: 407-734-3338
  • Fax:
Mailing address:
  • Phone: 407-558-0884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: