Provider Demographics
NPI:1154019800
Name:MAHONEY, AMANDA GACHET
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GACHET
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 N CENTRAL AVE APT 7202
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-8813
Mailing Address - Country:US
Mailing Address - Phone:714-904-9067
Mailing Address - Fax:
Practice Address - Street 1:540 S EREMLAND DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3186
Practice Address - Country:US
Practice Address - Phone:626-966-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14434101YP2500X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner