Provider Demographics
NPI:1235287517
Name:STREET, AMANDA (OT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:RAYBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 822394
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39182-2394
Mailing Address - Country:US
Mailing Address - Phone:601-638-4076
Mailing Address - Fax:601-638-4979
Practice Address - Street 1:960 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-9762
Practice Address - Country:US
Practice Address - Phone:662-260-3789
Practice Address - Fax:662-260-3790
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1818225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000050976OtherBCBS
MS05037726Medicaid