Provider Demographics
NPI:1073995221
Name:VAN DUSEN, AMANDA VICTORIA (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:VICTORIA
Last Name:VAN DUSEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:V
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:327 S K ST
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-5416
Mailing Address - Country:US
Mailing Address - Phone:559-688-2043
Mailing Address - Fax:559-688-1304
Practice Address - Street 1:327 S K ST
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-5416
Practice Address - Country:US
Practice Address - Phone:559-688-2043
Practice Address - Fax:559-688-1304
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93188106H00000X
CA121151106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health