Provider Demographics
NPI:1699026765
Name:MASTRUP, AMANDA MARIE (MA, LMFT 93544)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARIE
Last Name:MASTRUP
Suffix:
Gender:F
Credentials:MA, LMFT 93544
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94953-0375
Mailing Address - Country:US
Mailing Address - Phone:707-529-0220
Mailing Address - Fax:
Practice Address - Street 1:1360 N DUTTON AVE
Practice Address - Street 2:STE. 100
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4687
Practice Address - Country:US
Practice Address - Phone:707-529-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist