=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467204388
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA EFFERTZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2024
-----------------------------------------------------
Last Update Date | 04/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6328 ROWAN RD
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34653-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-505-0976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4151 NEWBURY DR
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-5757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-216-5729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | IMT4123
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------