Provider Demographics
NPI:1689034159
Name:HALE, AMANDA (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HALE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3343 ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9635
Mailing Address - Country:US
Mailing Address - Phone:541-840-6200
Mailing Address - Fax:541-973-2225
Practice Address - Street 1:3564 LONE PINE RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5637
Practice Address - Country:US
Practice Address - Phone:541-840-6200
Practice Address - Fax:541-973-2225
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20034225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist