Provider Demographics
NPI:1992430789
Name:JOHNSON, AMANDA LYNN (LBSC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LBSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 FALLON AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-1918
Mailing Address - Country:US
Mailing Address - Phone:302-893-9470
Mailing Address - Fax:
Practice Address - Street 1:213 FALLON AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-1918
Practice Address - Country:US
Practice Address - Phone:302-893-9470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH003333103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABH003333Medicaid