Provider Demographics
NPI:1609323625
Name:WOLKEN, AMANDA LEE (CMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:WOLKEN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CMT
Mailing Address - Street 1:2205 HALL ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-3501
Mailing Address - Country:US
Mailing Address - Phone:530-218-4342
Mailing Address - Fax:
Practice Address - Street 1:321 D ST
Practice Address - Street 2:SUITE F
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5902
Practice Address - Country:US
Practice Address - Phone:530-218-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54185225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist