Provider Demographics
NPI:1053164053
Name:GUILMETTE, AMANDA RAE (IS)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:GUILMETTE
Suffix:
Gender:F
Credentials:IS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 LAKE LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6619
Mailing Address - Country:US
Mailing Address - Phone:208-519-2278
Mailing Address - Fax:
Practice Address - Street 1:520 LAKE LOWELL AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6619
Practice Address - Country:US
Practice Address - Phone:208-519-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician