Provider Demographics
NPI:1073636262
Name:MCCALLUM, AMANDA (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17615 SE 272ND ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4957
Mailing Address - Country:US
Mailing Address - Phone:253-639-2266
Mailing Address - Fax:253-639-8464
Practice Address - Street 1:17615 SE 272ND ST
Practice Address - Street 2:SUITE 110
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4957
Practice Address - Country:US
Practice Address - Phone:253-639-2266
Practice Address - Fax:253-639-8464
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8807711Medicare ID - Type Unspecified