Provider Demographics
NPI:1487037693
Name:BROUGHTON, AMANDA JO (BCBA, LBA-OR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:BCBA, LBA-OR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 W BROADWAY APT 3
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2883
Mailing Address - Country:US
Mailing Address - Phone:949-326-8894
Mailing Address - Fax:
Practice Address - Street 1:339 W BROADWAY APT 3
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2883
Practice Address - Country:US
Practice Address - Phone:949-326-8894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500693767Medicaid