Provider Demographics
NPI:1457009441
Name:CRIST, AMANDA SHAE (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:SHAE
Last Name:CRIST
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 ELK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1460 ELK CREEK DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8237
Practice Address - Country:US
Practice Address - Phone:208-535-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-2352225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics