Provider Demographics
NPI:1982131678
Name:GRAY, AMANDA LYNN (MS, BCBA, IBA, LBA)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:LYNN
Last Name:GRAY
Suffix:
Gender:F
Credentials:MS, BCBA, IBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 MANDARIN LOOP
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:FL
Mailing Address - Zip Code:33838-4387
Mailing Address - Country:US
Mailing Address - Phone:305-934-6378
Mailing Address - Fax:863-869-6727
Practice Address - Street 1:2202 MANDARIN LOOP
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:FL
Practice Address - Zip Code:33838-4387
Practice Address - Country:US
Practice Address - Phone:833-869-2423
Practice Address - Fax:863-869-6727
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X, 251S00000X
FL1-21-54758103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-21-54758OtherBOARD CERTIFIED BEHAVIOR ANALYST (BCBA) WITH THE BACB
VA0133002472OtherLICENSED BEHAVIOR ANALYST (LBA) WITH THE VIRGINIA DHP
FL020898300Medicaid