MEDICARE: AMANDA JUAREZ

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

General Provider Information

NPI Number	:	1942896295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA JUAREZ

Provider Business Mailing Address
First Line	:	8763 PINE CREST PL
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-4657
Country	:	US
Telephone Number	:	818-524-8539
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 W OLD SHAKOPEE RD STE 102
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55438-2684
Country	:	US
Telephone Number	:	612-261-1503
Fax Number	:

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

Provider Enumeration Date	:	12/20/2020
Last Update Date	:	12/20/2020

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