Provider Demographics
NPI:1558876748
Name:ELLIS, AMANDA (RBT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:373 S WILLOW ST STE 266
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5751
Mailing Address - Country:US
Mailing Address - Phone:877-315-8080
Mailing Address - Fax:
Practice Address - Street 1:2751 LEGENDS PKWY STE 2
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-7754
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-10
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician