Provider Demographics
NPI:1073759932
Name:PEREZ, AMANDA CHEVON (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHEVON
Last Name:PEREZ
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 1:2519 S LAKELINE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2964
Mailing Address - Country:US
Mailing Address - Phone:512-331-6200
Mailing Address - Fax:512-331-6384
Practice Address - Street 1:2519 S LAKELINE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2964
Practice Address - Country:US
Practice Address - Phone:512-331-6200
Practice Address - Fax:512-331-6384
Is Sole Proprietor?:No
Enumeration Date:2008-12-24
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35047225100000X
NCP14294225100000X
TX1266663225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ44560AMedicare PIN