MEDICARE: AMANDA JENNINGS FARRIS LCSW

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	1041C0700X	Clinical Social Worker	SW17320	FL

General Provider Information

NPI Number	:	1205454329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JENNINGS FARRIS LCSW

Provider Business Mailing Address
First Line	:	720 BROOKER CREEK BLVD STE 215
Second Line	:
City	:	OLDSMAR
State	:	FL
Zip	:	34677-2937
Country	:	US
Telephone Number	:	813-854-9136
Fax Number	:	813-436-5378

Provider Business Practice Location Address
First Line	:	4911 S MANHATTAN AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-3429
Country	:	US
Telephone Number	:	813-471-9709
Fax Number	:	813-872-7766

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

Provider Enumeration Date	:	07/07/2020
Last Update Date	:	10/27/2023

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