Provider Demographics
NPI:1730635038
Name:WILD, AMANDA (EDD, BCBA, LBA, LABA)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name:WILD
Suffix:
Gender:
Credentials:EDD, BCBA, LBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-2007
Mailing Address - Country:US
Mailing Address - Phone:401-742-3977
Mailing Address - Fax:
Practice Address - Street 1:12531 CLIPPER DR STE 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2355
Practice Address - Country:US
Practice Address - Phone:571-398-0428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILBA00023103K00000X
103K00000X
VA0133003768103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst