Healthcare Provider Details

I. General information

NPI: 1972952042
Provider Name (Legal Business Name): AMANDA VISSERING LPCC, LMHC, PPSC
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: AJ VISSERING

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROFESSIONAL CENTER PKWY
SAN RAFAEL CA
94903-2757
US

IV. Provider business mailing address

8945 GOLF LINKS RD
OAKLAND CA
94605-4124
US

V. Phone/Fax

Practice location:
  • Phone: 206-572-0805
  • Fax:
Mailing address:
  • Phone: 510-654-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61129627
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8679
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number8679
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: