Healthcare Provider Details

I. General information

NPI: 1629583711
Provider Name (Legal Business Name): AMANDA KAUP MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2017
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1785 W 7888 S
WEST JORDAN UT
84088-4024
US

IV. Provider business mailing address

11328 S OLD BRIDGE RD
SOUTH JORDAN UT
84009-1273
US

V. Phone/Fax

Practice location:
  • Phone: 801-784-2914
  • Fax:
Mailing address:
  • Phone: 219-916-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12052694-2506
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: