Provider Demographics
NPI:1508628348
Name:FERNANDEZ DE LARA, AMANDA (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FERNANDEZ DE LARA
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 EVANS RD APT 2327
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-6979
Mailing Address - Country:US
Mailing Address - Phone:956-203-5831
Mailing Address - Fax:
Practice Address - Street 1:1042 FM306
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130
Practice Address - Country:US
Practice Address - Phone:830-507-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-24-70779103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst