Provider Demographics
NPI:1235491085
Name:CANTERBERRY, AMANDA J (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:CANTERBERRY
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 1:23297 HIGHWAY 53
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-8227
Mailing Address - Country:US
Mailing Address - Phone:228-261-9266
Mailing Address - Fax:
Practice Address - Street 1:23297 HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-8227
Practice Address - Country:US
Practice Address - Phone:228-261-9266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1943225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist