Provider Demographics
NPI:1164209953
Name:GODFREY, AMANDA (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GODFREY
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4223 HOLLEYS HILL ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3273
Mailing Address - Country:US
Mailing Address - Phone:760-710-7423
Mailing Address - Fax:
Practice Address - Street 1:850 LA SCONSA DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89138-7562
Practice Address - Country:US
Practice Address - Phone:702-526-5550
Practice Address - Fax:702-347-7649
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVOT-3326225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist