Basic Information
| Provider Information | |||||||||
| NPI: | 1386013522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENRIQUEZ | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 GOLFVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635197900 | ||||||||
| FaxNumber: | 8635197696 | ||||||||
| Practice Location | |||||||||
| Address1: | 1255 BRICE BLVD | ||||||||
| Address2: | |||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635198233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2015 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0155986 | 05 | FL | MEDICAID |