Provider Demographics
NPI:1245661727
Name:DISSMORE, AMANDA GRACE (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:GRACE
Last Name:DISSMORE
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:GRACE
Other - Last Name:JARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:8112 PAWTUCKET DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-6734
Mailing Address - Country:US
Mailing Address - Phone:714-552-1317
Mailing Address - Fax:
Practice Address - Street 1:8112 PAWTUCKET DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-6734
Practice Address - Country:US
Practice Address - Phone:714-552-1317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst