Provider Demographics
NPI:1972991958
Name:QAQISH, AMANDA GRACE LAZO (LMFT, PPS)
Entity type:Individual
Prefix:
First Name:AMANDA GRACE
Middle Name:LAZO
Last Name:QAQISH
Suffix:
Gender:F
Credentials:LMFT, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26087 ARROYO LN
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6520
Mailing Address - Country:US
Mailing Address - Phone:626-827-2218
Mailing Address - Fax:
Practice Address - Street 1:26087 ARROYO LN
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-6520
Practice Address - Country:US
Practice Address - Phone:626-827-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102948106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist