Provider Demographics
NPI:1861125221
Name:ZICCA, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ZICCA
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 1:633 SABAL LAKE DR APT 205
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-6048
Mailing Address - Country:US
Mailing Address - Phone:914-564-9510
Mailing Address - Fax:
Practice Address - Street 1:310 WAYMONT CT STE 100
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3475
Practice Address - Country:US
Practice Address - Phone:407-635-1979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH27024101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health