Provider Demographics
NPI:1780931642
Name:WORLEY, AMANDA W (PT, DPT, CMTPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:W
Last Name:WORLEY
Suffix:
Gender:F
Credentials:PT, DPT, CMTPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:R
Other - Last Name:WILKINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:9980 BROOK RD
Practice Address - Street 2:UNIT 16
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-6501
Practice Address - Country:US
Practice Address - Phone:804-550-5730
Practice Address - Fax:804-550-5733
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherMEDICARE GROUP PTAN
VA1780931642OtherMEDICAID QMB PROVIDER ID
VAC05954OtherMEDICARE GROUP PTAN