Provider Demographics
NPI:1609405737
Name:CHASE, AMANDA KATHLEEN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHLEEN
Last Name:CHASE
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 1:2731 NUGGET AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9456
Mailing Address - Country:US
Mailing Address - Phone:760-379-3412
Mailing Address - Fax:
Practice Address - Street 1:2731 NUGGET AVE
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9456
Practice Address - Country:US
Practice Address - Phone:760-379-3412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist