Healthcare Provider Details

I. General information

NPI: 1154762995
Provider Name (Legal Business Name): AMANDA CONNELLY BCABA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2013
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16414 SOUTHPARK DR
WESTFIELD IN
46074-8396
US

IV. Provider business mailing address

16414 SOUTHPARK DR
WESTFIELD IN
46074-8396
US

V. Phone/Fax

Practice location:
  • Phone: 317-815-5501
  • Fax:
Mailing address:
  • Phone: 404-735-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: