Provider Demographics
NPI:1154043370
Name:ROLLER, AMANDA NICOLE (MA, RMHCI)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:NICOLE
Last Name:ROLLER
Suffix:
Gender:F
Credentials:MA, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 SW 25TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-5470
Mailing Address - Country:US
Mailing Address - Phone:772-207-0852
Mailing Address - Fax:
Practice Address - Street 1:8280 COLLEGE PKWY STE 103
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-5122
Practice Address - Country:US
Practice Address - Phone:239-225-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH22917101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health