Provider Demographics
NPI:1063715498
Name:BIRD, AMANDA REA (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:REA
Last Name:BIRD
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:REA
Other - Last Name:MORSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5415 129TH PL APT 4
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-1282
Mailing Address - Country:US
Mailing Address - Phone:708-224-5581
Mailing Address - Fax:
Practice Address - Street 1:5415 129TH PL
Practice Address - Street 2:APT 4
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445
Practice Address - Country:US
Practice Address - Phone:708-224-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-14030103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-13-14030OtherBEHAVIOR ANALYST CERTIFICATION BOARD