Provider Demographics
NPI:1063914869
Name:FORISTER, AMANDA (MS)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:FORISTER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 OAK FERN CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4875
Mailing Address - Country:US
Mailing Address - Phone:307-363-2250
Mailing Address - Fax:
Practice Address - Street 1:12724 GRAN BAY PKWY W STE 410
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-9486
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1056101YM0800X
FLMH24302101YM0800X, 103K00000X
WYLPC1828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health