Provider Demographics
NPI:1720023773
Name:MAHONEY, AMANDA (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2970
Mailing Address - Fax:318-813-2981
Practice Address - Street 1:1450 CLAIBORNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4204
Practice Address - Country:US
Practice Address - Phone:318-813-2970
Practice Address - Fax:318-813-2981
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C878C749Medicare PIN