MEDICARE: AMANDA WILRISS 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	1-21-48399	NC

General Provider Information

NPI Number	:	1477138931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA WILRISS BCBA

Provider Business Mailing Address
First Line	:	3851 DUNHAGAN RD STE 102
Second Line	:
City	:	GREENVILLE
State	:	NC
Zip	:	27858-6640
Country	:	US
Telephone Number	:	252-751-0518
Fax Number	:

Provider Business Practice Location Address
First Line	:	3171 WRIGHTSVILLE AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4184
Country	:	US
Telephone Number	:	252-751-0518
Fax Number	:	252-565-4505

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

Provider Enumeration Date	:	03/16/2021
Last Update Date	:	03/16/2021

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