Provider Demographics
NPI:1619379542
Name:AMAZE BEHAVIOR THERAPY
Entity Type:Organization
Organization Name:AMAZE BEHAVIOR THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:WALLS
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:423-322-8796
Mailing Address - Street 1:3505 ADKISSON DR NW
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-6803
Mailing Address - Country:US
Mailing Address - Phone:423-322-8796
Mailing Address - Fax:423-473-6721
Practice Address - Street 1:3505 ADKISSON DR NW
Practice Address - Street 2:SUITE 208
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-6803
Practice Address - Country:US
Practice Address - Phone:423-322-8796
Practice Address - Fax:423-473-6721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-12-11707103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528677Medicaid