MEDICARE: AMANDA BISSONNETTE M.ED, BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-19-40056	GA

General Provider Information

NPI Number	:	1144779281
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA BISSONNETTE M.ED, BCBA

Provider Business Mailing Address
First Line	:	226 CREEKSTONE RDG
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-3732
Country	:	US
Telephone Number	:	678-996-4998
Fax Number	:	844-233-7089

Provider Business Practice Location Address
First Line	:	429 CREEKSTONE RDG
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-3746
Country	:	US
Telephone Number	:	678-996-4998
Fax Number	:	844-233-7089

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2016
Last Update Date	:	01/06/2020

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