Healthcare Provider Details

I. General information

NPI: 1336894260
Provider Name (Legal Business Name): AMANDA NICHOLE SORUM NONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4667 TELEGRAPH RD
VENTURA CA
93003-3899
US

IV. Provider business mailing address

600 W BROADWAY STE 300
GLENDALE CA
91204-1025
US

V. Phone/Fax

Practice location:
  • Phone: 805-289-6346
  • Fax:
Mailing address:
  • Phone: 818-722-1770
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number162296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: