Provider Demographics
NPI:1669761870
Name:AREVALO, AMANDA MARIA (LMT)
Entity type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:MARIA
Last Name:AREVALO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51539 SIMMONS RD
Mailing Address - Street 2:
Mailing Address - City:LORANGER
Mailing Address - State:LA
Mailing Address - Zip Code:70446-2447
Mailing Address - Country:US
Mailing Address - Phone:985-247-1344
Mailing Address - Fax:985-878-3869
Practice Address - Street 1:51539 SIMMONS RD
Practice Address - Street 2:
Practice Address - City:LORANGER
Practice Address - State:LA
Practice Address - Zip Code:70446-2447
Practice Address - Country:US
Practice Address - Phone:985-247-1344
Practice Address - Fax:985-878-3869
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5636225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist