Provider Demographics
NPI:1164990271
Name:BAZO, AMANDA KAGE (BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAGE
Last Name:BAZO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N PALAFOX ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-2678
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3208 GULF BREEZE PKWY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3350
Practice Address - Country:US
Practice Address - Phone:800-676-5130
Practice Address - Fax:888-958-5753
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA010301053OtherDRIVER'S LICENSE