Provider Demographics
NPI:1316578636
Name:AIKEN, AMANDA MONTEZ
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MONTEZ
Last Name:AIKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 TODD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ELLENTON
Mailing Address - State:SC
Mailing Address - Zip Code:29809-2824
Mailing Address - Country:US
Mailing Address - Phone:803-226-3245
Mailing Address - Fax:
Practice Address - Street 1:550 EASTGATE DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-7688
Practice Address - Country:US
Practice Address - Phone:803-643-3694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3488224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant