Provider Demographics
NPI:1104013283
Name:JOHNSON, AMANDA S
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:MERTENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:218 N PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64050-2655
Mailing Address - Country:US
Mailing Address - Phone:816-521-2700
Mailing Address - Fax:816-521-2999
Practice Address - Street 1:218 N PLEASANT ST
Practice Address - Street 2:INDEPENDENCE SCHOOL DISTRICT
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-2655
Practice Address - Country:US
Practice Address - Phone:816-521-2700
Practice Address - Fax:816-521-2999
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000164618225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist