MEDICARE: MARISA BROOKE AMENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1083197255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA BROOKE AMENT

Provider Business Mailing Address
First Line	:	1883 WISCONSIN AVE
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-4721
Country	:	US
Telephone Number	:	717-869-2913
Fax Number	:

Provider Business Practice Location Address
First Line	:	1883 WISCONSIN AVE
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-4721
Country	:	US
Telephone Number	:	717-869-2913
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	07/19/2021

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Directions to “ MARISA BROOKE AMENT ” Practice Location

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