Provider Demographics
NPI:1689017782
Name:REBEL, AMANDA H
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:H
Last Name:REBEL
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 1:3219 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-5910
Mailing Address - Country:US
Mailing Address - Phone:843-415-9193
Mailing Address - Fax:
Practice Address - Street 1:3219 PIERCE ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-5910
Practice Address - Country:US
Practice Address - Phone:843-415-9193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95115106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist