Provider Demographics
NPI:1164916201
Name:FORD, AMANDA ROSE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 STONELEIGH AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-3990
Mailing Address - Country:US
Mailing Address - Phone:845-279-1785
Mailing Address - Fax:
Practice Address - Street 1:664 STONELEIGH AVE STE 202
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-3990
Practice Address - Country:US
Practice Address - Phone:845-279-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038124-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist