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General NPI Number Information
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NPI Number | 1619379542
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Entity Type | Organization
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Legal Business Name | AMAZE BEHAVIOR THERAPY
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Dates
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Enumeration Date | 09/23/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 3505 ADKISSON DR NW SUITE 208
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City | CLEVELAND
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State | TN
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Zip | 37312-6803
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Country | US
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Telephone | 423-322-8796
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Fax | 423-473-6721
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Provider Business Mailing Address
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Address Line | 3505 ADKISSON DR NW SUITE 208
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City | CLEVELAND
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State | TN
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Zip | 37312-6803
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Country | US
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Telephone | 423-322-8796
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Fax | 423-473-6721
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Authorized Official
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Title or Position | OWNER/CLINICAL DIRECTOR
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Name | MS. CARRIE EILEEN WALLS
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Credential | BCBA
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Telephone | 423-322-8796
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 1-12-11707
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License Number State | TN
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