MEDICARE: DR. AMANDA THALJI-RAITANO PH.D.

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	103T00000X	Psychologist	PY9857	FL

General Provider Information

NPI Number	:	1679996144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMANDA THALJI-RAITANO PH.D.

Provider Business Mailing Address
First Line	:	518 33RD AVE N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33704-1218
Country	:	US
Telephone Number	:	727-543-3235
Fax Number	:

Provider Business Practice Location Address
First Line	:	840 BEACH DR NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33701-2012
Country	:	US
Telephone Number	:	727-543-3235
Fax Number	:

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

Provider Enumeration Date	:	02/03/2014
Last Update Date	:	09/14/2021

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