Basic Information
| Provider Information | |||||||||
| NPI: | 1407265150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVKOVICH | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W WATERS AVE | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336341229 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2909 W BAY TO BAY BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336298100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133815200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2014 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH14091 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.