Provider Demographics
NPI:1689413056
Name:AMATANGELO, BRAXTON JAIDEN
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:JAIDEN
Last Name:AMATANGELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 N MADDERLAKE PL APT 3
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-1629
Mailing Address - Country:US
Mailing Address - Phone:986-888-7008
Mailing Address - Fax:
Practice Address - Street 1:1087 E PARK BLVD SUITE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:986-888-7008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician