Provider Demographics
NPI:1922574995
Name:BOCK, AMANDA RAE (ATC)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:RAE
Last Name:BOCK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NW 128TH DR APT 301
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-5202
Mailing Address - Country:US
Mailing Address - Phone:661-645-6811
Mailing Address - Fax:
Practice Address - Street 1:3301 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-7721
Practice Address - Country:US
Practice Address - Phone:954-262-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL53882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty