Basic Information
| Provider Information | |||||||||
| NPI: | 1316284565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMADOR | ||||||||
| FirstName: | MABELIN | ||||||||
| MiddleName: | ALTAGRACIA | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 SW PALM DR APT 104 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349861945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7729855484 | ||||||||
| FaxNumber: | 8633578269 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 NW 5TH ST | ||||||||
| Address2: | |||||||||
| City: | OKEECHOBEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349722565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633578268 | ||||||||
| FaxNumber: | 8633578269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2013 | ||||||||
| LastUpdateDate: | 01/08/2013 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.