Provider Demographics
NPI:1992411524
Name:LOPEZ, AMANDA MICHELLE (ASW #114024)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:ASW #114024
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2037 W BULLARD AVE # 121
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-1233
Mailing Address - Country:US
Mailing Address - Phone:559-250-4461
Mailing Address - Fax:
Practice Address - Street 1:23370 ROAD 22
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-8504
Practice Address - Country:US
Practice Address - Phone:559-250-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-26
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114024104100000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker