Healthcare Provider Details

I. General information

NPI: 1144594565
Provider Name (Legal Business Name): AMANDA GARRETTSON M.A. BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA SMITH

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6867 SOUTHPOINT DR N
JACKSONVILLE FL
32216-8043
US

IV. Provider business mailing address

2198 BLUE HERON COVE DR
ORANGE PARK FL
32003-4929
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-6071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-10332
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: