Healthcare Provider Details

I. General information

NPI: 1619623964
Provider Name (Legal Business Name): AMANDA JANE MOORE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SPRING ST STE 203
LA MESA CA
91942-0273
US

IV. Provider business mailing address

PO BOX 2763
SPRING VALLEY CA
91979-2763
US

V. Phone/Fax

Practice location:
  • Phone: 619-549-0329
  • Fax:
Mailing address:
  • Phone: 619-634-7537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11201
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: