Provider Demographics
NPI:1689171522
Name:MCCARTHY, AMANDA LEIGH (MOTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 SUMAC CIR
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5622
Mailing Address - Country:US
Mailing Address - Phone:612-802-2415
Mailing Address - Fax:
Practice Address - Street 1:5842 HOBE LN
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-6477
Practice Address - Country:US
Practice Address - Phone:651-383-1197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104602225XM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1609320605Medicaid
MN1609320605OtherEVOLVE WELL OCCUPATIONAL THERAPY