Healthcare Provider Details

I. General information

NPI: 1780466219
Provider Name (Legal Business Name): AMANDA DANIELLE ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 E MERCED ST
FOWLER CA
93625
US

IV. Provider business mailing address

311 E MERCED ST
FOWLER CA
93625-2316
US

V. Phone/Fax

Practice location:
  • Phone: 559-892-9452
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC20603
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT157143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: