Provider Demographics
NPI:1801458252
Name:TEBO, AMANDA DAWN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
Last Name:TEBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:DAWN
Other - Last Name:DREW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:131 KING ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3234
Mailing Address - Country:US
Mailing Address - Phone:413-665-8717
Mailing Address - Fax:413-665-9383
Practice Address - Street 1:131 KING ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3234
Practice Address - Country:US
Practice Address - Phone:413-665-8717
Practice Address - Fax:413-665-9383
Is Sole Proprietor?:No
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210423172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker