Provider Demographics
NPI:1891294484
Name:MCKIBBEN, AMANDA (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4091 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2429
Mailing Address - Country:US
Mailing Address - Phone:831-239-3312
Mailing Address - Fax:
Practice Address - Street 1:2361 E 29TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-3511
Practice Address - Country:US
Practice Address - Phone:510-488-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15157225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist