Provider Demographics
NPI:1992127633
Name:PENN, AMANDA V (MA, RMHCI)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:V
Last Name:PENN
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 1:3610 SAN JACINTO CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6123
Mailing Address - Country:US
Mailing Address - Phone:407-963-3756
Mailing Address - Fax:
Practice Address - Street 1:3610 SAN JACINTO CIR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6123
Practice Address - Country:US
Practice Address - Phone:407-963-3756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH11880101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health