Provider Demographics
NPI:1053965111
Name:AMANTINE, DYROL
Entity type:Individual
Prefix:
First Name:DYROL
Middle Name:
Last Name:AMANTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 283
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92564-0283
Mailing Address - Country:US
Mailing Address - Phone:909-721-0548
Mailing Address - Fax:
Practice Address - Street 1:31772 CASINO DR STE A
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4502
Practice Address - Country:US
Practice Address - Phone:909-721-0548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-27
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT108592106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist