Healthcare Provider Details

I. General information

NPI: 1629522701
Provider Name (Legal Business Name): ASHLEY NICHOLLE AMARILLAS MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY AMARILLAS-RUELAS

II. Dates (important events)

Enumeration Date: 08/07/2016
Last Update Date: 01/11/2022
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINS DR
MODESTO CA
95358-6400
US

IV. Provider business mailing address

300 PULLMAN ST
LIVERMORE CA
94551-9756
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-1750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10YP2500X
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number123999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: