Basic Information
| Provider Information | |||||||||
| NPI: | 1164740858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IANNITELLI | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | DEBORAH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9671 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321209671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767175 | ||||||||
| FaxNumber: | 3866767134 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 S NOVA RD | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321748445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 015044900 | 05 | FL | MEDICAID |