Provider Demographics
NPI:1245712975
Name:BAUCOM, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BAUCOM
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 1:3329 235TH ST
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742-9205
Mailing Address - Country:US
Mailing Address - Phone:432-661-2262
Mailing Address - Fax:
Practice Address - Street 1:604 OAKWOOD DR
Practice Address - Street 2:
Practice Address - City:STRONGHURST
Practice Address - State:IL
Practice Address - Zip Code:61480-5052
Practice Address - Country:US
Practice Address - Phone:309-924-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011582225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist