Provider Demographics
NPI:1073392353
Name:SPAW, AMANDA GRAHAM (MOT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRAHAM
Last Name:SPAW
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:GRAHAM
Other - Last Name:BAKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:670 ALBEMARLE DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-5947
Mailing Address - Country:US
Mailing Address - Phone:318-828-1450
Mailing Address - Fax:
Practice Address - Street 1:2122 AIRLINE DR STE 200
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3270
Practice Address - Country:US
Practice Address - Phone:318-828-1450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty