Provider Demographics
NPI:1629285101
Name:ROEBUCK, AMANDA LEE (LMP, APP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:ROEBUCK
Suffix:
Gender:F
Credentials:LMP, APP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 SAN FRANCISCO AVE NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-4074
Mailing Address - Country:US
Mailing Address - Phone:360-480-0342
Mailing Address - Fax:360-943-6860
Practice Address - Street 1:1016 SAN FRANCISCO AVE NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-4074
Practice Address - Country:US
Practice Address - Phone:360-480-0342
Practice Address - Fax:360-943-6860
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist