Provider Demographics
NPI:1235531682
Name:WHITLEY, AMANDA (OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:BAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3214 WINCHESTER
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2929
Mailing Address - Country:US
Mailing Address - Phone:501-794-6482
Mailing Address - Fax:501-794-6483
Practice Address - Street 1:3214 WINCHESTER
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2929
Practice Address - Country:US
Practice Address - Phone:501-794-6482
Practice Address - Fax:501-794-6483
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2726225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR205964721Medicaid
AR205964721Medicaid