Healthcare Provider Details

I. General information

NPI: 1659552602
Provider Name (Legal Business Name): AMY KO EARNHART MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS AMY KO

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 BEACH BLVD STE. 245
BUENA PARK CA
90621-2840
US

IV. Provider business mailing address

6301 BEACH BLVD STE. 245
BUENA PARK CA
90621-2840
US

V. Phone/Fax

Practice location:
  • Phone: 714-736-0231
  • Fax: 714-736-0895
Mailing address:
  • Phone: 714-736-0231
  • Fax: 714-736-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF76868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: