Provider Demographics
NPI:1952013120
Name:KIRK, AMANDA ANNE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANNE
Last Name:KIRK
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4584 OLD HIGHWAY 11
Mailing Address - Street 2:
Mailing Address - City:PURVIS
Mailing Address - State:MS
Mailing Address - Zip Code:39475-3506
Mailing Address - Country:US
Mailing Address - Phone:601-520-4637
Mailing Address - Fax:
Practice Address - Street 1:6752 U S HIGHWAY 98
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8443
Practice Address - Country:US
Practice Address - Phone:601-264-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS220008103K00000X
1-21-56111103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-56111OtherBACB CERTIFICATION NUMBER
MS220008OtherLICENSED BEHAVIOR ANALYST