Healthcare Provider Details

I. General information

NPI: 1144570474
Provider Name (Legal Business Name): AMANDA JOY WATERS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

IV. Provider business mailing address

75 HOCKANUM BLVD UNIT 735
VERNON CT
06066-4056
US

V. Phone/Fax

Practice location:
  • Phone: 310-668-3096
  • Fax: 310-223-0910
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number003624
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: