Healthcare Provider Details

I. General information

NPI: 1396034765
Provider Name (Legal Business Name): AMY NICOLE WICK M.S., BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 MAGIC HOLLOW BLVD
VIRGINIA BEACH VA
23453-1632
US

IV. Provider business mailing address

3101 MAGIC HOLLOW BLVD
VIRGINIA BEACH VA
23453
US

V. Phone/Fax

Practice location:
  • Phone: 757-639-2218
  • Fax:
Mailing address:
  • Phone: 757-639-2218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-10-7212
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133001186
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: