MEDICARE: AMANDA WHITE

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	106S00000X	Behavior Technician	BACB1191657	ID

General Provider Information

NPI Number	:	1538995626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA WHITE

Provider Business Mailing Address
First Line	:	4471 OLD HIGHWAY 191
Second Line	:
City	:	ISLAND PARK
State	:	ID
Zip	:	83429-5053
Country	:	US
Telephone Number	:	986-800-1295
Fax Number	:

Provider Business Practice Location Address
First Line	:	859 S YELLOWSTONE HWY
Second Line	:
City	:	REXBURG
State	:	ID
Zip	:	83440-5293
Country	:	US
Telephone Number	:	307-257-5487
Fax Number	:

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

Provider Enumeration Date	:	09/13/2024
Last Update Date	:	09/18/2024

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Directions to “ AMANDA WHITE ” Practice Location

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