Provider Demographics
NPI:1881325579
Name:LONG, AMANDA DONETTE (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DONETTE
Last Name:LONG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 W YELLOWJACKET LN APT 1216
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4858
Mailing Address - Country:US
Mailing Address - Phone:214-218-4364
Mailing Address - Fax:
Practice Address - Street 1:963 W YELLOWJACKET LN
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4950
Practice Address - Country:US
Practice Address - Phone:972-722-5129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2131998225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant