Provider Demographics
NPI:1063847168
Name:CHOMA, AMANDA BLAIR (MA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:BLAIR
Last Name:CHOMA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:BLAIR
Other - Last Name:CHOMA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BCBA
Mailing Address - Street 1:1253 HERKIMER RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-1043
Mailing Address - Country:US
Mailing Address - Phone:908-910-9077
Mailing Address - Fax:
Practice Address - Street 1:615 LACEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2200
Practice Address - Country:US
Practice Address - Phone:609-242-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-08
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-14-15109103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst