Provider Demographics
NPI:1194309906
Name:HIGGINBOTHEM, AMANDA S (RBT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:HIGGINBOTHEM
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 ARMENA RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4228
Mailing Address - Country:US
Mailing Address - Phone:229-343-2573
Mailing Address - Fax:
Practice Address - Street 1:175 WHITNEY RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:GA
Practice Address - Zip Code:31763-3020
Practice Address - Country:US
Practice Address - Phone:229-886-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB647031106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician