Provider Demographics
NPI:1912204371
Name:AMANTINE, KRISTEN NICOLE (BA)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:NICOLE
Last Name:AMANTINE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1212 W AVENUE J STE 200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2940
Mailing Address - Country:US
Mailing Address - Phone:661-220-5508
Mailing Address - Fax:818-991-7722
Practice Address - Street 1:1212 W AVENUE J STE 200
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-220-5508
Practice Address - Fax:818-991-7722
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health