Provider Demographics
NPI:1639324601
Name:HEINEMAN, AMANDA SKYE (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SKYE
Last Name:HEINEMAN
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6147 SUTTER AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2738
Mailing Address - Country:US
Mailing Address - Phone:916-847-7736
Mailing Address - Fax:
Practice Address - Street 1:6147 SUTTER AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2738
Practice Address - Country:US
Practice Address - Phone:916-847-7736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF #61188106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist