Provider Demographics
NPI:1396355459
Name:FERNANDEZ, AMANDA MICHELLE (MA, BCBA, LBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:MA, BCBA, LBA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:LACOUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:5859 W TALAVI BLVD STE 180
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1873
Practice Address - Country:US
Practice Address - Phone:602-560-2836
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-20-120709106S00000X
AZBEH-000975103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-22-60394OtherBCBA CERTIFICATE