Provider Demographics
NPI:1417178195
Name:DIVINE, AMANDA NUGENT (MS, LMFT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NUGENT
Last Name:DIVINE
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 LAMBETH DR
Mailing Address - Street 2:
Mailing Address - City:RESCUE
Mailing Address - State:CA
Mailing Address - Zip Code:95672-9391
Mailing Address - Country:US
Mailing Address - Phone:310-663-0752
Mailing Address - Fax:
Practice Address - Street 1:3780 ROSIN CT
Practice Address - Street 2:SUITE 110
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1646
Practice Address - Country:US
Practice Address - Phone:916-417-7374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46360106H00000X
TX67208101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional