Provider Demographics
NPI:1134645260
Name:GILLIS, AMANDA J (BCBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:GILLIS
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:J
Other - Last Name:KIRKLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2083 NEWNAN CROSSING BLVD E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2606
Practice Address - Country:US
Practice Address - Phone:470-241-1408
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-19-38023103K00000X
GA1-19-38023103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL17-39189OtherRBT CERTIFICATION