Provider Demographics
NPI:1982237558
Name:BEZILLA, AMANDA (BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BEZILLA
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 1:10011 STONELAKE BLVD APT 269
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-0009
Mailing Address - Country:US
Mailing Address - Phone:918-261-6717
Mailing Address - Fax:
Practice Address - Street 1:900 N CUERNAVACA DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78733-3218
Practice Address - Country:US
Practice Address - Phone:512-772-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2628103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst