Provider Demographics
NPI:1144613258
Name:WALDIE, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:WALDIE
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 1:6009 PINE BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-8882
Mailing Address - Country:US
Mailing Address - Phone:352-408-8644
Mailing Address - Fax:
Practice Address - Street 1:1217 HUFFSTETLER RD
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-8225
Practice Address - Country:US
Practice Address - Phone:352-483-1652
Practice Address - Fax:352-360-6582
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health