Provider Demographics
NPI:1336394071
Name:OW, AMY M
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:OW
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:PO BOX 772
Mailing Address - Street 2:
Mailing Address - City:PEBBLE BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93953-0772
Mailing Address - Country:US
Mailing Address - Phone:831-373-1403
Mailing Address - Fax:
Practice Address - Street 1:350 E 17TH ST
Practice Address - Street 2:SUITE #111
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3231
Practice Address - Country:US
Practice Address - Phone:831-373-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14693225700000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program