Provider Demographics
NPI:1962542399
Name:SMITH, AMANDA NICOLE (AMANDA CARD)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AMANDA CARD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:NICOLE
Other - Last Name:CARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AMANDA CARD
Mailing Address - Street 1:3469 PIEDMONT DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-1850
Mailing Address - Country:US
Mailing Address - Phone:909-534-7494
Mailing Address - Fax:
Practice Address - Street 1:537 CAJON ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5903
Practice Address - Country:US
Practice Address - Phone:909-534-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA284871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health