Provider Demographics
NPI:1073205274
Name:VINCENT, AMANDA LYNN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:VINCENT
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 1:41760 IVY ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9415
Mailing Address - Country:US
Mailing Address - Phone:951-595-4673
Mailing Address - Fax:
Practice Address - Street 1:41760 IVY ST
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9415
Practice Address - Country:US
Practice Address - Phone:951-595-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician