Provider Demographics
NPI:1669840070
Name:WEAVER, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12604 WINDY RIDGE DR NW
Mailing Address - Street 2:
Mailing Address - City:MOUNT SAVAGE
Mailing Address - State:MD
Mailing Address - Zip Code:21545-1438
Mailing Address - Country:US
Mailing Address - Phone:304-641-8488
Mailing Address - Fax:
Practice Address - Street 1:12604 WINDY RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:MOUNT SAVAGE
Practice Address - State:MD
Practice Address - Zip Code:21545-1438
Practice Address - Country:US
Practice Address - Phone:304-641-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4583225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist