Provider Demographics
NPI:1578288676
Name:ROBERTS, AMANDA MARIE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:ROBERTS
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 1:5160 ILCHESTER WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6308
Mailing Address - Country:US
Mailing Address - Phone:443-750-0503
Mailing Address - Fax:
Practice Address - Street 1:9550 GORMAN RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-5916
Practice Address - Country:US
Practice Address - Phone:410-880-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD09408225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist