MEDICARE: MISS AMANDA GATLIN A.A.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1134496680
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMANDA GATLIN A.A.S

Provider Business Mailing Address
First Line	:	3240 W MESCAL ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4123
Country	:	US
Telephone Number	:	602-578-7958
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 W MESCAL ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85029-4123
Country	:	US
Telephone Number	:	602-578-7958
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2011
Last Update Date	:	11/29/2011

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