Provider Demographics
NPI:1790343812
Name:LIEVENDAG, AMANDA JEAN (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:LIEVENDAG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 BANK CT STE 110
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-2886
Mailing Address - Country:US
Mailing Address - Phone:240-651-1335
Mailing Address - Fax:
Practice Address - Street 1:7200 BANK CT STE 110
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-2886
Practice Address - Country:US
Practice Address - Phone:240-651-1335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist