Provider Demographics
NPI:1194135954
Name:MICHAELIS, AMY LYN (MED, BCBA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYN
Last Name:MICHAELIS
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6815 PLUMPJACK CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-4083
Mailing Address - Country:US
Mailing Address - Phone:386-689-5262
Mailing Address - Fax:
Practice Address - Street 1:6815 PLUMPJACK CT
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-4083
Practice Address - Country:US
Practice Address - Phone:386-689-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other