Provider Demographics
NPI:1245279611
Name:DEYO, AMANDA NICOLE (OT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICOLE
Last Name:DEYO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 BEACON RD
Mailing Address - Street 2:
Mailing Address - City:GLENMONT
Mailing Address - State:NY
Mailing Address - Zip Code:12077-3244
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:20 PEACHTREE CT
Practice Address - Street 2:#105
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4616
Practice Address - Country:US
Practice Address - Phone:631-467-3700
Practice Address - Fax:631-467-0928
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013398225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA9685Medicare PIN