Provider Demographics
NPI:1538995626
Name:WHITE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WHITE
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 1:4471 OLD HIGHWAY 191
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:ID
Mailing Address - Zip Code:83429-5053
Mailing Address - Country:US
Mailing Address - Phone:986-800-1295
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5293
Practice Address - Country:US
Practice Address - Phone:307-257-5487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDBACB1191657106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician