Healthcare Provider Details

I. General information

NPI: 1124324066
Provider Name (Legal Business Name): AMANDA MARIE KUGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 VIA CALLEJON SUITE B
SAN CLEMENTE CA
92673
US

IV. Provider business mailing address

19 CALLE PELICANO
SAN CLEMENTE CA
92673
US

V. Phone/Fax

Practice location:
  • Phone: 949-498-5100
  • Fax:
Mailing address:
  • Phone: 949-887-1510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP 13536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: