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Individual

AMANDA ICENOGLE

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F

Contact information

Practice address
2543 ROSS CLARK CIR, DOTHAN, AL 36301-4925
(334) 699-4007
(334) 699-4014
Mailing address
60 COUNTY ROAD 755, ENTERPRISE, AL 36330-1553
(334) 464-0063

Taxonomy

Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
103K00000X

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
133086
AL
Enumeration date
05/25/2021
Last updated
05/25/2021
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