Provider Demographics
NPI:1790438554
Name:CONVERSE-RATH, AMANDA MICHELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:CONVERSE-RATH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MICHELLE
Other - Last Name:BROTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7202 ALLIANCE CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-1522
Mailing Address - Country:US
Mailing Address - Phone:619-733-3859
Mailing Address - Fax:
Practice Address - Street 1:8755 AERO DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1750
Practice Address - Country:US
Practice Address - Phone:619-587-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23250225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist