Provider Demographics
NPI:1922704311
Name:CALLAHAN, AMANDA JEAN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 IRVING ST SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6361
Mailing Address - Country:US
Mailing Address - Phone:360-489-2704
Mailing Address - Fax:
Practice Address - Street 1:128 D ST SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4064
Practice Address - Country:US
Practice Address - Phone:360-570-9580
Practice Address - Fax:360-570-9583
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61343386225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist