Basic Information
| Provider Information | |||||||||
| NPI: | 1003454414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE WOLF | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3474 CANYON RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | ALTADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910013724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263901803 | ||||||||
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| Practice Location | |||||||||
| Address1: | 66 HURLBUT ST | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911054025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264414221 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2019 | ||||||||
| LastUpdateDate: | 12/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.