Provider Demographics
NPI:1346746153
Name:CLARK, AMANDA M (BCBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:CLARK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-1338
Mailing Address - Country:US
Mailing Address - Phone:802-674-4428
Mailing Address - Fax:
Practice Address - Street 1:147 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-1338
Practice Address - Country:US
Practice Address - Phone:802-674-4428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0-18-8495103K00000X
VT146.0134209103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst