Provider Demographics
NPI:1184902074
Name:GORHAM, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GORHAM
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 1:29371 INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018-3053
Mailing Address - Country:US
Mailing Address - Phone:573-690-5850
Mailing Address - Fax:
Practice Address - Street 1:29371 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-3053
Practice Address - Country:US
Practice Address - Phone:573-690-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011024108225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist