Healthcare Provider Details

I. General information

NPI: 1558938225
Provider Name (Legal Business Name): AMANDA MARYNNE RODOLA M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA OLLER M.A.

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 08/21/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W VISTA WAY
VISTA CA
92083-5704
US

IV. Provider business mailing address

1660 HOTEL CIR N STE AND314
SAN DIEGO CA
92108-2807
US

V. Phone/Fax

Practice location:
  • Phone: 760-940-1836
  • Fax:
Mailing address:
  • Phone: 619-961-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number101YA0400X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number94027351
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSB94027351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: