Provider Demographics
NPI:1952940173
Name:VAN DYKE, AMANDA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:2303 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2174
Mailing Address - Country:US
Mailing Address - Phone:573-406-8378
Mailing Address - Fax:
Practice Address - Street 1:1950 E 70TH ST STE A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5345
Practice Address - Country:US
Practice Address - Phone:318-219-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA325638225X00000X
MO2019036905225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist