Healthcare Provider Details

I. General information

NPI: 1538565965
Provider Name (Legal Business Name): AMANDA PEARMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 06/05/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 KETTNER BLVD STE 1A4
SAN DIEGO CA
92101-1252
US

IV. Provider business mailing address

2535 KETTNER BLVD STE 1A4
SAN DIEGO CA
92101-1252
US

V. Phone/Fax

Practice location:
  • Phone: 619-615-0701
  • Fax:
Mailing address:
  • Phone: 619-615-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3127
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: