Provider Demographics
NPI:1790942217
Name:BERANEK, AMANDA F (OTR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:F
Last Name:BERANEK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:F
Other - Last Name:SYLLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:300 S BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1934
Mailing Address - Country:US
Mailing Address - Phone:507-537-9172
Mailing Address - Fax:
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-537-9172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0724225X00000X
MN103494225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1790942217Medicaid
MN1790942217Medicaid
SDS102887Medicare PIN