Provider Demographics
NPI:1376861021
Name:DWORKIN, AMANDA B (AT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:B
Last Name:DWORKIN
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-802-1991
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:1108 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2039
Practice Address - Country:US
Practice Address - Phone:770-749-0250
Practice Address - Fax:770-749-0086
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0015162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer