Provider Demographics
NPI:1417464876
Name:LAGRANGE, AMANDA WALL (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:WALL
Last Name:LAGRANGE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:GWEN
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:1925A TURNBURY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-6168
Mailing Address - Country:US
Mailing Address - Phone:252-341-9944
Mailing Address - Fax:252-439-0957
Practice Address - Street 1:1925A TURNBURY DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-6168
Practice Address - Country:US
Practice Address - Phone:252-341-9944
Practice Address - Fax:252-439-0957
Is Sole Proprietor?:No
Enumeration Date:2018-01-08
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11531225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist