Provider Demographics
NPI:1659947984
Name:WILBUR, AMANDA M
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:WILBUR
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 1:2751 RECHE CANYON RD UNIT SP85
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9570
Mailing Address - Country:US
Mailing Address - Phone:951-285-9890
Mailing Address - Fax:
Practice Address - Street 1:6840 INDIANA AVE STE 275
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4279
Practice Address - Country:US
Practice Address - Phone:951-788-0230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW993731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00000000OtherPRIVATE