Provider Demographics
NPI:1144594565
Name:GARRETTSON, AMANDA (MA BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GARRETTSON
Suffix:
Gender:F
Credentials:MA BCBA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2198 BLUE HERON COVE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-4929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6867 SOUTHPOINT DR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8043
Practice Address - Country:US
Practice Address - Phone:904-619-6071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-12-10332103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst