Provider Demographics
NPI:1396215851
Name:PRADO, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:PRADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35318 LUCIA ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-5456
Mailing Address - Country:US
Mailing Address - Phone:510-579-6884
Mailing Address - Fax:
Practice Address - Street 1:751A CAMINO PLZ
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3401
Practice Address - Country:US
Practice Address - Phone:650-627-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-47965106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician