Provider Demographics
NPI:1164117537
Name:BURCH, AMANDA ROSE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:BURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 FOOTHILL BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-4579
Mailing Address - Country:US
Mailing Address - Phone:818-446-7488
Mailing Address - Fax:
Practice Address - Street 1:2600 FOOTHILL BLVD STE 203
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-4579
Practice Address - Country:US
Practice Address - Phone:818-446-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA149706106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program