Healthcare Provider Details

I. General information

NPI: 1932933959
Provider Name (Legal Business Name): AMANDA VASHAKIDZE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 SNYDER LN
ROHNERT PARK CA
94928-2906
US

IV. Provider business mailing address

2570 ACACIA AVE
SONOMA CA
95476-9723
US

V. Phone/Fax

Practice location:
  • Phone: 707-792-4750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: