Provider Demographics
NPI:1194992669
Name:FODOR, AMY ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:FODOR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:DEWALT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1555 INDIAN RIVER BLVD STE B210
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7113
Mailing Address - Country:US
Mailing Address - Phone:772-257-8224
Mailing Address - Fax:772-252-3245
Practice Address - Street 1:1545 9TH ST SW
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32962-4312
Practice Address - Country:US
Practice Address - Phone:772-257-8224
Practice Address - Fax:772-252-3245
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW3798101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW3798OtherSTATE LICENSE