Provider Demographics
NPI:1548779622
Name:DATEMA, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DATEMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6678 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-2861
Mailing Address - Country:US
Mailing Address - Phone:530-876-1006
Mailing Address - Fax:530-876-8225
Practice Address - Street 1:6678 CLARK RD
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-2861
Practice Address - Country:US
Practice Address - Phone:530-876-1006
Practice Address - Fax:530-876-8225
Is Sole Proprietor?:No
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT293664225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist