Healthcare Provider Details

I. General information

NPI: 1104584077
Provider Name (Legal Business Name): AMY LYNN PLOUFFE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 W PLANO PKWY STE 200
PLANO TX
75093-4855
US

IV. Provider business mailing address

18726 S WESTERN AVE
GARDENA CA
90248-3813
US

V. Phone/Fax

Practice location:
  • Phone: 725-197-2665
  • Fax:
Mailing address:
  • Phone: 310-856-0800
  • Fax: 855-568-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: