Provider Demographics
NPI:1750629184
Name:CAMPO, AMANDA ELLEN (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELLEN
Last Name:CAMPO
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 MONTE CARLO WAY
Mailing Address - Street 2:APT 625
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-1487
Mailing Address - Country:US
Mailing Address - Phone:631-965-2589
Mailing Address - Fax:
Practice Address - Street 1:4113 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5609
Practice Address - Country:US
Practice Address - Phone:817-793-7764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017786225X00000X
TX117332225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist