Basic Information
| Provider Information | |||||||||
| NPI: | 1700374295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GITTLESON | ||||||||
| FirstName: | AMANDA | ||||||||
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| Credential: | BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 INTERNATIONAL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | 4075886294 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 W MONROE ST STE G600 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492022171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177951598 | ||||||||
| FaxNumber: | 7342122255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 7401001396 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.