Provider Demographics
NPI:1376748327
Name:DOUGLASS, AMANDA S (DPT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:S
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 16TH ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6595
Mailing Address - Country:US
Mailing Address - Phone:904-471-5117
Mailing Address - Fax:
Practice Address - Street 1:4201 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1431
Practice Address - Country:US
Practice Address - Phone:904-296-5811
Practice Address - Fax:904-296-5810
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22464225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist