Healthcare Provider Details

I. General information

NPI: 1982376174
Provider Name (Legal Business Name): MS. AMANDA MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 JEFFERSON ST
FAIRFIELD CA
94533-6293
US

IV. Provider business mailing address

609 JEFFERSON ST
FAIRFIELD CA
94533-6293
US

V. Phone/Fax

Practice location:
  • Phone: 707-399-9190
  • Fax:
Mailing address:
  • Phone: 707-399-9190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: