Basic Information
| Provider Information | |||||||||
| NPI: | 1285903203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELDRUM-MAGANA | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ENGELDRUM | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 411 E LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950764424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317286445 | ||||||||
| FaxNumber: | 8317244251 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 E LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950764424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317286445 | ||||||||
| FaxNumber: | 8317244251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2011 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | LCSW110773 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.