Provider Demographics
NPI:1720557796
Name:LAROSE, AMANDA LYNN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:LAROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 E BAKERSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05441-9725
Mailing Address - Country:US
Mailing Address - Phone:802-782-5460
Mailing Address - Fax:
Practice Address - Street 1:37 TALCOTT RD STE 114
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-2094
Practice Address - Country:US
Practice Address - Phone:802-235-9322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1-18-31867103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst