Provider Demographics
NPI:1902564362
Name:GARDILL, AMY (MS BCBA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:GARDILL
Suffix:
Gender:F
Credentials:MS BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7460 CENTRAL BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23513-2818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1514 HOLLAND RD STE 2
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6517
Practice Address - Country:US
Practice Address - Phone:757-644-6391
Practice Address - Fax:757-622-2011
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
VARBT-21-177688106S00000X
VA1-23-63861103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician