Provider Demographics
NPI:1831568310
Name:TAYLOR, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SHAFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:EAST BUILDING, ROOM M146
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:612-273-8400
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:EAST BUILDING, ROOM M146
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-273-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104983225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist