Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003454414 |
---|---|
Provider Name | Amanda Jane De Wolf |
First Address | Altadena, CA 91001-3724 |
Second Address | Pasadena, CA 91105-4025 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/12/2019 |
Last Update Date | 16/12/2019 |