Healthcare Provider Details

I. General information

NPI: 1467990366
Provider Name (Legal Business Name): AMANDA JOHNSON MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 2
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

224 W GRAHAM AVE
LAKE ELSINORE CA
92530-3740
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax:
Mailing address:
  • Phone: 951-318-1351
  • Fax: 866-288-5478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF96265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: