Healthcare Provider Details

I. General information

NPI: 1558413195
Provider Name (Legal Business Name): AMANDA ROSE VIERRA LAADC, MAC, ICCDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4637 COLUMBIA RIVER CT
SAN JOSE CA
95136-2765
US

IV. Provider business mailing address

4637 COLUMBIA RIVER CT
SAN JOSE CA
95136-2765
US

V. Phone/Fax

Practice location:
  • Phone: 408-365-4559
  • Fax:
Mailing address:
  • Phone: 408-365-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLR01860216
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: