Provider Demographics
NPI:1164755427
Name:FATA, AMANDA JEANNA
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:JEANNA
Last Name:FATA
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 1:100 BAYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02779-2200
Mailing Address - Country:US
Mailing Address - Phone:508-685-8268
Mailing Address - Fax:508-880-6848
Practice Address - Street 1:1328 2ND ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1122
Practice Address - Country:US
Practice Address - Phone:310-394-6889
Practice Address - Fax:310-394-6883
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical