Basic Information
| Provider Information | |||||||||
| NPI: | 1336667609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONESMITH | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PARKER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BCBA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 813 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | GRIFFITH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463192230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199026442 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 440 EDMOND DR | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193221415 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2017 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-16-24152 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1780630525 | 01 | IN | NA | OTHER |