Provider Demographics
NPI:1669080297
Name:COUCH, AMANDA LYN (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LYN
Last Name:COUCH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 W BATON ROUGE PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-2022
Mailing Address - Country:US
Mailing Address - Phone:208-221-4599
Mailing Address - Fax:
Practice Address - Street 1:2208 W DETROIT ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3629
Practice Address - Country:US
Practice Address - Phone:918-900-6237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-20-44619103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst