Provider Demographics
NPI:1730890856
Name:CARLSON, AMANDA (BCBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GUETZKOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6225 SMITH AVE STE 1001A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 N PARKER DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3021
Practice Address - Country:US
Practice Address - Phone:608-662-9327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1051103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst