Provider Demographics
NPI:1104979475
Name:VANN, AMANDA (IMF)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VANN
Suffix:
Gender:F
Credentials:IMF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1812
Mailing Address - Country:US
Mailing Address - Phone:619-797-1090
Mailing Address - Fax:619-797-1091
Practice Address - Street 1:3845 SPRING DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-1030
Practice Address - Country:US
Practice Address - Phone:619-797-1090
Practice Address - Fax:619-797-1091
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017412101YM0800X
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495954612Medicaid