Provider Demographics
NPI:1558413195
Name:VIERRA, AMANDA ROSE (LAADC, MAC, ICCDP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:ROSE
Last Name:VIERRA
Suffix:
Gender:F
Credentials:LAADC, MAC, ICCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4637 COLUMBIA RIVER CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-2765
Mailing Address - Country:US
Mailing Address - Phone:408-365-4559
Mailing Address - Fax:
Practice Address - Street 1:4637 COLUMBIA RIVER CT
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95136-2765
Practice Address - Country:US
Practice Address - Phone:408-365-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 174H00000X
CALR01860216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator