Provider Demographics
NPI:1962992891
Name:BLAIR, AMANDA MARY (RBT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARY
Last Name:BLAIR
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 1:268 BUSH ST STE 3039
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-3503
Mailing Address - Country:US
Mailing Address - Phone:888-362-3970
Mailing Address - Fax:
Practice Address - Street 1:428 E THUNDERBIRD RD STE 138
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5229
Practice Address - Country:US
Practice Address - Phone:888-362-3970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT-18-48953106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician