Provider Demographics
NPI:1659876902
Name:MESSINA-GODFREY, AMANDA R (BCBA 1-18-29787)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:MESSINA-GODFREY
Suffix:
Gender:F
Credentials:BCBA 1-18-29787
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PAVON
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-3752
Mailing Address - Country:US
Mailing Address - Phone:805-304-9968
Mailing Address - Fax:
Practice Address - Street 1:124 PAVON
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-3752
Practice Address - Country:US
Practice Address - Phone:805-304-9968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-29787103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst