Healthcare Provider Details

I. General information

NPI: 1417178195
Provider Name (Legal Business Name): AMANDA NUGENT DIVINE M.S., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 ROSIN CT SUITE 110
SACRAMENTO CA
95834-1646
US

IV. Provider business mailing address

3533 LAMBETH DR
RESCUE CA
95672-9391
US

V. Phone/Fax

Practice location:
  • Phone: 916-417-7374
  • Fax:
Mailing address:
  • Phone: 310-663-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number67208
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number46360
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: