Provider Demographics
NPI:1649474610
Name:UTTERBACK, AMANDA MICHELLE (MPT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MICHELLE
Last Name:UTTERBACK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9117 NATHAN DR
Mailing Address - Street 2:
Mailing Address - City:WHITE SETTLEMENT
Mailing Address - State:TX
Mailing Address - Zip Code:76108-3551
Mailing Address - Country:US
Mailing Address - Phone:806-470-1192
Mailing Address - Fax:
Practice Address - Street 1:925 SANTA FE DR STE 111
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5867
Practice Address - Country:US
Practice Address - Phone:817-594-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1175159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist