Provider Demographics
NPI:1528380961
Name:BAXTER, AMANDA L (OTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BAXTER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 BILL BRADFORD
Mailing Address - Street 2:STE 101
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75482-4538
Mailing Address - Country:US
Mailing Address - Phone:903-885-5919
Mailing Address - Fax:
Practice Address - Street 1:614 BILL BRADFORD
Practice Address - Street 2:STE 101
Practice Address - City:SULPHUR SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75482-4538
Practice Address - Country:US
Practice Address - Phone:903-885-5919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210663224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210663OtherPT OT BOARD LICENSE NUMBER