Healthcare Provider Details

I. General information

NPI: 1104979475
Provider Name (Legal Business Name): AMANDA VANN IMF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3845 SPRING DR
SPRING VALLEY CA
91977-1030
US

IV. Provider business mailing address

3434 GROVE ST
LEMON GROVE CA
91945-1812
US

V. Phone/Fax

Practice location:
  • Phone: 619-797-1090
  • Fax: 619-797-1091
Mailing address:
  • Phone: 619-797-1090
  • Fax: 619-797-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2002017412
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: