Healthcare Provider Details

I. General information

NPI: 1053965111
Provider Name (Legal Business Name): DYROL AMANTINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2019
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23990 EUCALYPTUS AVE
MORENO VALLEY CA
92553-5504
US

IV. Provider business mailing address

PO BOX 283
MURRIETA CA
92564-0283
US

V. Phone/Fax

Practice location:
  • Phone: 909-721-0548
  • Fax:
Mailing address:
  • Phone: 909-721-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT149266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: