Provider Demographics
NPI:1790376630
Name:BENNETT, AMANDA B (RBT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:B
Last Name:BENNETT
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 1:106 ANDERSON WAY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1601
Mailing Address - Country:US
Mailing Address - Phone:912-342-0996
Mailing Address - Fax:912-342-4977
Practice Address - Street 1:106 ANDERSON WAY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1601
Practice Address - Country:US
Practice Address - Phone:912-342-0996
Practice Address - Fax:912-342-4977
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT153391106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty