Provider Demographics
NPI:1932450798
Name:STINE, AMANDA AYUMI IBARAKI
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:AYUMI IBARAKI
Last Name:STINE
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 1:4432 48TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4018
Mailing Address - Country:US
Mailing Address - Phone:650-207-8232
Mailing Address - Fax:
Practice Address - Street 1:4219 SW JUNEAU ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1621
Practice Address - Country:US
Practice Address - Phone:206-207-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76440106H00000X
WAMG60882994106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist