Provider Demographics
NPI:1386174324
Name:SRISATHAPAT, AMANDA HEIM (LAC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:HEIM
Last Name:SRISATHAPAT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18909 FLORWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5631
Mailing Address - Country:US
Mailing Address - Phone:949-274-0344
Mailing Address - Fax:
Practice Address - Street 1:10000 FLOWER ST
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90706-5413
Practice Address - Country:US
Practice Address - Phone:562-804-3449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17502171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist