Provider Demographics
NPI:1598150823
Name:WHITEHEAD, AMANDA (PTA)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 MARINE DR
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21409-4745
Mailing Address - Country:US
Mailing Address - Phone:410-507-9108
Mailing Address - Fax:
Practice Address - Street 1:957 MARINE DR
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21409-4745
Practice Address - Country:US
Practice Address - Phone:410-507-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3965225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant