Provider Demographics
NPI:1003014028
Name:HART, AMY DIANE (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DIANE
Last Name:HART
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 W RIVERSIDE DR STE 106
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4050
Mailing Address - Country:US
Mailing Address - Phone:818-512-4179
Mailing Address - Fax:818-805-3108
Practice Address - Street 1:4405 W RIVERSIDE DR STE 106
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4050
Practice Address - Country:US
Practice Address - Phone:818-512-4179
Practice Address - Fax:818-805-3108
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50296106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist