Provider Demographics
NPI:1396583605
Name:MEZZACAPA, AMANDA (MFT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MEZZACAPA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-5455
Mailing Address - Country:US
Mailing Address - Phone:707-321-5208
Mailing Address - Fax:
Practice Address - Street 1:111 PRIMROSE LN
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-5455
Practice Address - Country:US
Practice Address - Phone:707-321-5208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122005101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health