Provider Demographics
NPI:1669685624
Name:MCQUEEN, AMANDA WHEATLEY (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:WHEATLEY
Last Name:MCQUEEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JO
Other - Last Name:WHEATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:5000 HAZEL AVE
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-4933
Mailing Address - Country:US
Mailing Address - Phone:412-559-9770
Mailing Address - Fax:
Practice Address - Street 1:601 N CAROLINE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-955-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 8377225200000X
MD25660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD25660OtherPT LICENSE