Provider Demographics
NPI:1982924635
Name:MOORE, AMANDA MARTIN (DPT, OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARTIN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3328 BEMISS RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-7014
Mailing Address - Country:US
Mailing Address - Phone:229-244-1201
Mailing Address - Fax:229-244-1207
Practice Address - Street 1:3328 BEMISS RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7014
Practice Address - Country:US
Practice Address - Phone:229-244-1201
Practice Address - Fax:229-244-1207
Is Sole Proprietor?:No
Enumeration Date:2010-06-04
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009863225100000X
GAOT005039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist