Provider Demographics
NPI:1831592724
Name:ST ROMAIN, AMANDA (BCBA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ST ROMAIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ROYAL CREST DR
Mailing Address - Street 2:#113
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-2603
Mailing Address - Country:US
Mailing Address - Phone:318-240-3575
Mailing Address - Fax:
Practice Address - Street 1:1600 ROYAL CREST DR
Practice Address - Street 2:#113
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-2603
Practice Address - Country:US
Practice Address - Phone:318-240-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1149780103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst