Provider Demographics
NPI:1578901724
Name:SUPECK, AMANDA (OTR/ L)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:SUPECK
Suffix:
Gender:F
Credentials:OTR/ L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3447 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:TN
Mailing Address - Zip Code:38225-2430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 HANNINGS LN
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3308
Practice Address - Country:US
Practice Address - Phone:731-587-3193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2629225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist