Provider Demographics
NPI:1457740243
Name:BARHAM, AMBER DYAN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:DYAN
Last Name:BARHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:AMBER
Other - Middle Name:DYAN
Other - Last Name:BLODGETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:841 NE INDEPENDENCE CT
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2567
Mailing Address - Country:US
Mailing Address - Phone:816-642-4394
Mailing Address - Fax:
Practice Address - Street 1:505 NE ADAMS DAIRY PKWY
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-5487
Practice Address - Country:US
Practice Address - Phone:816-988-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY66 009768225200000X
MO2016013016225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant