Provider Demographics
NPI:1679265086
Name:BARDALES, AMANDA EMILIA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:EMILIA
Last Name:BARDALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WILLIS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02125-4364
Mailing Address - Country:US
Mailing Address - Phone:562-338-8571
Mailing Address - Fax:
Practice Address - Street 1:24 WILLIS ST APT 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02125-4364
Practice Address - Country:US
Practice Address - Phone:562-338-8571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst