Basic Information
| Provider Information | |||||||||
| NPI: | 1730534496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMANIEH | ||||||||
| FirstName: | HALEH | ||||||||
| MiddleName: | |||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 MIDDLE STREET | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | 8666100580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 NW 56TH TER | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528355520 | ||||||||
| FaxNumber: | 8666100580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 11/01/2016 | ||||||||
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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 | 106S00000X | RBT-16-18582 | FL | Y |
ID Information
| ID | Type | State | Issuer | Description | 009093700 | 05 | FL | MEDICAID |