Provider Demographics
NPI:1023563145
Name:LY, AMANDA ANNIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNIE
Last Name:LY
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:PO BOX 6021
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91802-6021
Mailing Address - Country:US
Mailing Address - Phone:626-888-3859
Mailing Address - Fax:
Practice Address - Street 1:1000 E WALNUT ST STE 225
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-1434
Practice Address - Country:US
Practice Address - Phone:626-888-3859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100476106H00000X
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist