Provider Demographics
NPI:1053943662
Name:HOLLOWAY, AMANDA NICOLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4274 SW KAZAN ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7247
Mailing Address - Country:US
Mailing Address - Phone:772-812-5225
Mailing Address - Fax:
Practice Address - Street 1:4181 SW HIGH MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-3725
Practice Address - Country:US
Practice Address - Phone:772-222-5560
Practice Address - Fax:844-652-8088
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician