Basic Information
| Provider Information | |||||||||
| NPI: | 1255990446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REWOLDT | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11323 MOUNTAIN VIEW DR APT 206 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917308309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628880906 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1950 SUNWEST LN | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924153124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092524010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2019 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 4195-226 | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.