=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104979475
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA VANN IMF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 02/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3845 SPRING DR
-----------------------------------------------------
City | SPRING VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91977-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-797-1090
-----------------------------------------------------
Fax | 619-797-1091
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3434 GROVE ST
-----------------------------------------------------
City | LEMON GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91945-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-797-1090
-----------------------------------------------------
Fax | 619-797-1091
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 2002017412
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------