Provider Demographics
NPI:1770711806
Name:GURGANUS, AMANDA CAROLINE (MA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CAROLINE
Last Name:GURGANUS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:GURGANUS
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:117 38TH PL
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-3105
Mailing Address - Country:US
Mailing Address - Phone:310-749-2684
Mailing Address - Fax:
Practice Address - Street 1:1703 COUNTRY CLUB RD STE 204
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6006
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:910-347-6137
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC200600453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program