=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215420138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA LYN DEPAOLO LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2018
-----------------------------------------------------
Last Update Date | 08/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1660 HOTEL CIR N STE 101
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92108-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-961-2120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24516 CAMINO MIRABELLA
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-4333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-647-3126
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 99056
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------