Provider Demographics
NPI:1982317913
Name:THARALDSON, AMANDA LYNN (OTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:THARALDSON
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3609 KINGS POINT CT APT E
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-1680
Mailing Address - Country:US
Mailing Address - Phone:386-747-6587
Mailing Address - Fax:
Practice Address - Street 1:201 EPPES ST
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2717
Practice Address - Country:US
Practice Address - Phone:804-541-1445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131001765224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant