Basic Information
| Provider Information | |||||||||
| NPI: | 1164755427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FATA | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | JEANNA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 BAYVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | BERKLEY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027792200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086858268 | ||||||||
| FaxNumber: | 5088806848 | ||||||||
| Practice Location | |||||||||
| Address1: | 1328 2ND ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904011122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103946889 | ||||||||
| FaxNumber: | 3103946883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2009 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.