Healthcare Provider Details

I. General information

NPI: 1366333015
Provider Name (Legal Business Name): AMANDA LYNN VANCE CADTP 20172
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 W WHITES BRIDGE AVE
FRESNO CA
93706-1225
US

IV. Provider business mailing address

2445 W WHITES BRIDGE AVE
FRESNO CA
93706-1225
US

V. Phone/Fax

Practice location:
  • Phone: 559-264-5096
  • Fax:
Mailing address:
  • Phone: 559-264-5096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: