Provider Demographics
NPI:1154602878
Name:AMY FODOR, LCSW, INC
Entity type:Organization
Organization Name:AMY FODOR, LCSW, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FODOR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:772-766-2069
Mailing Address - Street 1:801 GRANDIN AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-5125
Mailing Address - Country:US
Mailing Address - Phone:772-766-2069
Mailing Address - Fax:772-918-8468
Practice Address - Street 1:699 17TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6251
Practice Address - Country:US
Practice Address - Phone:772-766-2069
Practice Address - Fax:772-918-8468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW37981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty