Provider Demographics
NPI:1245446103
Name:KEEGAN, AMANDA EDWARDS (MPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:EDWARDS
Last Name:KEEGAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12616 SE STARK ST BLDG L
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1058
Mailing Address - Country:US
Mailing Address - Phone:360-480-5859
Mailing Address - Fax:503-408-0791
Practice Address - Street 1:12616 SE STARK ST BLDG L
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:360-480-5859
Practice Address - Fax:503-408-0791
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5018225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist