Provider Demographics
NPI:1457810459
Name:KING, AMANDA (OTR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:3453 TWIN PINES DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-1125
Mailing Address - Country:US
Mailing Address - Phone:214-315-3877
Mailing Address - Fax:
Practice Address - Street 1:200 COUNTRY BROOK DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2125
Practice Address - Country:US
Practice Address - Phone:817-380-5451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115367225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist