Healthcare Provider Details

I. General information

NPI: 1376199471
Provider Name (Legal Business Name): AMANDA MARIE COLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 MICHAEL DR
SOUTH LAKE TAHOE CA
96150-3344
US

IV. Provider business mailing address

PO BOX 2566
SOUTH LAKE TAHOE CA
96158-4066
US

V. Phone/Fax

Practice location:
  • Phone: 805-707-4864
  • Fax:
Mailing address:
  • Phone: 805-707-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT164750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: