Healthcare Provider Details

I. General information

NPI: 1669351953
Provider Name (Legal Business Name): AMANDA GUMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 FALLS DR
FORT WAYNE IN
46804-7147
US

IV. Provider business mailing address

5750 FALLS DR
FORT WAYNE IN
46804-7147
US

V. Phone/Fax

Practice location:
  • Phone: 260-204-5719
  • Fax:
Mailing address:
  • Phone: 260-204-5719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-24-375729
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-375729
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: