Provider Demographics
NPI:1447906813
Name:SMITH, AMIE JEANNE
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:JEANNE
Last Name:SMITH
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 1:200 PAGE BACON RD APT 3316
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1765
Mailing Address - Country:US
Mailing Address - Phone:401-489-0550
Mailing Address - Fax:
Practice Address - Street 1:340 W 23RD ST STE B
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4541
Practice Address - Country:US
Practice Address - Phone:401-489-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21830101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health