Provider Demographics
NPI:1295201887
Name:FLYCKT, AMANDA ALLEN (OTD, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ALLEN
Last Name:FLYCKT
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MAOT, OTR/L
Mailing Address - Street 1:1932 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1932 14TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-4605
Practice Address - Country:US
Practice Address - Phone:310-344-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19334225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics