Provider Demographics
NPI:1144779281
Name:BISSONNETTE, AMANDA (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BISSONNETTE
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BISSONNETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCBA
Mailing Address - Street 1:226 CREEKSTONE RDG
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3732
Mailing Address - Country:US
Mailing Address - Phone:678-996-4998
Mailing Address - Fax:844-233-7089
Practice Address - Street 1:429 CREEKSTONE RDG
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3746
Practice Address - Country:US
Practice Address - Phone:678-996-4998
Practice Address - Fax:844-233-7089
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-19-40056103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst