Provider Demographics
NPI:1740761725
Name:CANDRIAN, AMY TAYLOR (BCBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:TAYLOR
Last Name:CANDRIAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 RAYIPA LN
Mailing Address - Street 2:
Mailing Address - City:TRINIDAD
Mailing Address - State:CA
Mailing Address - Zip Code:95570-9617
Mailing Address - Country:US
Mailing Address - Phone:805-550-0817
Mailing Address - Fax:
Practice Address - Street 1:3300 BROADWAY
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3809
Practice Address - Country:US
Practice Address - Phone:805-550-0817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-30372103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst