Provider Demographics
NPI:1871249128
Name:DALE, AMANDA (RBT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DALE
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 1:305 SHIELD DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-4363
Mailing Address - Country:US
Mailing Address - Phone:256-689-9606
Mailing Address - Fax:
Practice Address - Street 1:124 E MIRACLE STRIP PKWY
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1988
Practice Address - Country:US
Practice Address - Phone:850-301-0438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician