Provider Demographics
NPI:1043522857
Name:LANG, AMANDA ELLEN (MS, BCBA)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:ELLEN
Last Name:LANG
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 FORT FLORIDA RD
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-9714
Mailing Address - Country:US
Mailing Address - Phone:386-562-0170
Mailing Address - Fax:888-338-8312
Practice Address - Street 1:454 FORT FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713
Practice Address - Country:US
Practice Address - Phone:386-562-0170
Practice Address - Fax:888-338-8312
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-08
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-08-4879103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst