Provider Demographics
NPI:1982310470
Name:AMANDA MARIE ESPY FAMILY THERAPY, INC.
Entity Type:Organization
Organization Name:AMANDA MARIE ESPY FAMILY THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ESPY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-291-1249
Mailing Address - Street 1:827 4TH ST APT 408
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1277
Mailing Address - Country:US
Mailing Address - Phone:424-291-1249
Mailing Address - Fax:
Practice Address - Street 1:185 PIER AVE STE 104
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-5360
Practice Address - Country:US
Practice Address - Phone:424-291-1249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760950109Medicaid
CA1760950109OtherNPI