Provider Demographics
NPI:1366868853
Name:SHORT, AMANDA LEE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LEE
Last Name:SHORT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:DODSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1014 S MOUNT CARMEL PL
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6604
Mailing Address - Country:US
Mailing Address - Phone:620-235-1500
Mailing Address - Fax:620-235-1508
Practice Address - Street 1:1014 S MOUNT CARMEL PL
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6604
Practice Address - Country:US
Practice Address - Phone:620-235-1500
Practice Address - Fax:620-235-1508
Is Sole Proprietor?:No
Enumeration Date:2014-03-09
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013011398225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant