Provider Demographics
NPI:1336653153
Name:ENDERLI, AMY (BCBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ENDERLI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1618 HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23325-3840
Mailing Address - Country:US
Mailing Address - Phone:309-212-5021
Mailing Address - Fax:
Practice Address - Street 1:4225 PORTSMOUTH BLVD STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-2154
Practice Address - Country:US
Practice Address - Phone:309-212-5021
Practice Address - Fax:757-282-7585
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-18-33052103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023139300Medicaid