Healthcare Provider Details

I. General information

NPI: 1356055149
Provider Name (Legal Business Name): AMANDA ROBERTSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 PLACERVILLE DR STE 2
PLACERVILLE CA
95667-4200
US

IV. Provider business mailing address

670 PLACERVILLE DR STE 2
PLACERVILLE CA
95667-4200
US

V. Phone/Fax

Practice location:
  • Phone: 530-644-2412
  • Fax:
Mailing address:
  • Phone: 530-644-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: