Provider Demographics
NPI:1942826441
Name:WALLIN, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WALLIN
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 1:26137 LA PAZ RD STE 230
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5337
Mailing Address - Country:US
Mailing Address - Phone:949-595-8610
Mailing Address - Fax:
Practice Address - Street 1:26137 LA PAZ RD STE 230
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5337
Practice Address - Country:US
Practice Address - Phone:949-595-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker