Provider Demographics
NPI:1649793548
Name:STAYROOK, AMANDA MICHELLE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MICHELLE
Last Name:STAYROOK
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 1:6416 PHEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4175
Mailing Address - Country:US
Mailing Address - Phone:937-470-4091
Mailing Address - Fax:
Practice Address - Street 1:512 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2718
Practice Address - Country:US
Practice Address - Phone:937-335-7161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-23
Last Update Date:2017-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH367998224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty