Healthcare Provider Details

I. General information

NPI: 1992667562
Provider Name (Legal Business Name): AMANDA NICOLE RICCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 BRITTANY PARK DR APT 222
ANTIOCH TN
37013-5054
US

IV. Provider business mailing address

950 BRITTANY PARK DR APT 222
ANTIOCH TN
37013-5054
US

V. Phone/Fax

Practice location:
  • Phone: 708-724-4945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number152.003207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: