Healthcare Provider Details

I. General information

NPI: 1861185480
Provider Name (Legal Business Name): AMANDA MARIAM KHALIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5051 CANYON CREST DR STE 204
RIVERSIDE CA
92507-6035
US

IV. Provider business mailing address

420 N MCKINLEY ST STE 111-287
CORONA CA
92879-8099
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-1488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT138609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: