Basic Information
| Provider Information | |||||||||
| NPI: | 1588621288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITLEY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORELOCK | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 GULF BREEZE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325617808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 GULF BREEZE PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | GULF BREEZE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325617808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509163700 | ||||||||
| FaxNumber: | 8509163710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OT18370 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT003606 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.