Provider Demographics
NPI:1477620250
Name:TILTON MARTIN, AMANDA (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TILTON MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 VT ROUTE 109
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05492-9518
Mailing Address - Country:US
Mailing Address - Phone:802-644-6364
Mailing Address - Fax:
Practice Address - Street 1:56 OLD FARM RD
Practice Address - Street 2:
Practice Address - City:STOWE
Practice Address - State:VT
Practice Address - Zip Code:05672-4434
Practice Address - Country:US
Practice Address - Phone:802-253-6852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003034225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009723Medicaid
VTVN3160Medicare ID - Type Unspecified