Provider Demographics
NPI:1629498639
Name:GADDIS, AMANDA NICOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:GADDIS
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 1:15095 AMARGOSA RD STE 201
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-1875
Mailing Address - Country:US
Mailing Address - Phone:760-780-4091
Mailing Address - Fax:
Practice Address - Street 1:265 SAN JACINTO RIVER RD STE 107
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4400
Practice Address - Country:US
Practice Address - Phone:951-674-9243
Practice Address - Fax:951-674-9635
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137781106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist