Provider Demographics
NPI:1003454414
Name:DE WOLF, AMANDA JANE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:DE WOLF
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 1:3474 CANYON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3724
Mailing Address - Country:US
Mailing Address - Phone:626-390-1803
Mailing Address - Fax:
Practice Address - Street 1:66 HURLBUT ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-4025
Practice Address - Country:US
Practice Address - Phone:626-441-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)