Provider Demographics
NPI:1306325022
Name:ANDERSEN, AMANDA JEAN (LMFT, MA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:LMFT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CLOVER
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8368
Mailing Address - Country:US
Mailing Address - Phone:949-344-6566
Mailing Address - Fax:
Practice Address - Street 1:17744 SKY PARK CIR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6421
Practice Address - Country:US
Practice Address - Phone:949-344-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102510101Y00000X
101Y00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA102510OtherMFTA