Provider Demographics
NPI:1275961351
Name:MOYLE, AMANDA (CMT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MOYLE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3023 BUNKER HILL ST
Mailing Address - Street 2:201
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5706
Mailing Address - Country:US
Mailing Address - Phone:619-786-2611
Mailing Address - Fax:
Practice Address - Street 1:3023 BUNKER HILL ST
Practice Address - Street 2:201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5706
Practice Address - Country:US
Practice Address - Phone:619-786-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15788OtherCALIFORNIA MASSAGE THERAPY COUNCIL