Provider Demographics
NPI:1225228539
Name:AJMAL, AMANDA CARRIE (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CARRIE
Last Name:AJMAL
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 1:11088 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-6126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 E HOLT AVE
Practice Address - Street 2:B
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5406
Practice Address - Country:US
Practice Address - Phone:909-620-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47092106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist