Provider Demographics
NPI:1518302322
Name:PERRON, AMANDA RAE (OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:PERRON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 S JONES BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6793
Mailing Address - Country:US
Mailing Address - Phone:702-360-1137
Mailing Address - Fax:702-240-1729
Practice Address - Street 1:2012 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3151
Practice Address - Country:US
Practice Address - Phone:702-360-1137
Practice Address - Fax:702-240-1729
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2014-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2591225X00000X
NV14-0458225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR196599721Medicaid