Provider Demographics
NPI:1407204563
Name:TOMAC, AMANDA J (LMT)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:J
Last Name:TOMAC
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 SE 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4241
Mailing Address - Country:US
Mailing Address - Phone:815-347-1052
Mailing Address - Fax:
Practice Address - Street 1:322 NW 5TH AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3825
Practice Address - Country:US
Practice Address - Phone:815-347-1052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22269225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist