Provider Demographics
NPI:1194489328
Name:BAGBY, AMANDA NATALIE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NATALIE
Last Name:BAGBY
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N LOOMIS ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1147
Mailing Address - Country:US
Mailing Address - Phone:312-243-8487
Mailing Address - Fax:
Practice Address - Street 1:1233 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1147
Practice Address - Country:US
Practice Address - Phone:312-243-8487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-19-107281106S00000X
IL12366459103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician