Provider Demographics
NPI:1730515917
Name:WILSON, AMY REBECCA (BCBA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:REBECCA
Last Name:WILSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:REBECCA
Other - Last Name:BLACKHOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1333 S MAYFLOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5239
Mailing Address - Country:US
Mailing Address - Phone:818-241-6780
Mailing Address - Fax:888-588-2752
Practice Address - Street 1:1520 NUTMEG PL STE 110
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-2557
Practice Address - Country:US
Practice Address - Phone:855-295-3276
Practice Address - Fax:885-882-7528
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst