MEDICARE: AMANDA NICOLE GATES BA

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		GA

General Provider Information

NPI Number	:	1790248599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA NICOLE GATES BA

Provider Business Mailing Address
First Line	:	2909 CAMPBELLTON RD SW APT 19G
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-4509
Country	:	US
Telephone Number	:	404-740-0562
Fax Number	:

Provider Business Practice Location Address
First Line	:	2909 CAMPBELLTON RD SW APT 19G
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-4509
Country	:	US
Telephone Number	:	404-740-0562
Fax Number	:

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

Provider Enumeration Date	:	04/09/2019
Last Update Date	:	04/09/2019

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Directions to “ AMANDA NICOLE GATES BA” Practice Location

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