Provider Demographics
NPI:1457724395
Name:LUBETICH, AMANDA (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LUBETICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 HELENE ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2817
Mailing Address - Country:US
Mailing Address - Phone:805-587-8580
Mailing Address - Fax:
Practice Address - Street 1:4050 HELENE ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2817
Practice Address - Country:US
Practice Address - Phone:805-587-8580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-31
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10449225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant