Provider Demographics
NPI:1952061285
Name:ANDERSON, AMY (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LONE STAR DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79766-9025
Mailing Address - Country:US
Mailing Address - Phone:432-272-9338
Mailing Address - Fax:
Practice Address - Street 1:848 CENTRAL DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4202
Practice Address - Country:US
Practice Address - Phone:432-400-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-21-52353103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst