Provider Demographics
NPI:1417583980
Name:OSORIO, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:OSORIO
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 1:17219 SEQUOIA ST APT 20
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1413
Mailing Address - Country:US
Mailing Address - Phone:562-419-9803
Mailing Address - Fax:
Practice Address - Street 1:17219 SEQUOIA ST APT 20
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1413
Practice Address - Country:US
Practice Address - Phone:562-419-9803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD8554016OtherDRIVER'S LICENSE