Provider Demographics
NPI:1821642281
Name:BEVERLY, AMANDA JANE (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:BEVERLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 BEVINS LN STE D
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-6145
Mailing Address - Country:US
Mailing Address - Phone:502-868-6008
Mailing Address - Fax:
Practice Address - Street 1:204 BEVINS LN STE D
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-6145
Practice Address - Country:US
Practice Address - Phone:502-868-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173372225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist