Provider Demographics
NPI:1205209699
Name:SKORUPSKI, AMANDA (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SKORUPSKI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:GA
Mailing Address - Zip Code:31305-0734
Mailing Address - Country:US
Mailing Address - Phone:912-261-1017
Mailing Address - Fax:912-554-3980
Practice Address - Street 1:1049 DANIEL WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:TOWNSEND
Practice Address - State:GA
Practice Address - Zip Code:31331-7408
Practice Address - Country:US
Practice Address - Phone:912-230-6490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008258225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist