Provider Demographics
NPI:1831457571
Name:COTTON, AMANDA DANIELLE (CMT)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:DANIELLE
Last Name:COTTON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11256
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1256
Mailing Address - Country:US
Mailing Address - Phone:909-255-9331
Mailing Address - Fax:
Practice Address - Street 1:316 N MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5115
Practice Address - Country:US
Practice Address - Phone:909-255-9331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31523225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist