Healthcare Provider Details

I. General information

NPI: 1295201887
Provider Name (Legal Business Name): AMANDA ALLEN FLYCKT OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA MICHELLE ALLEN MAOT, OTR/L

II. Dates (important events)

Enumeration Date: 10/22/2018
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 PARK CREST DR
CARDIFF BY THE SEA CA
92007-1427
US

IV. Provider business mailing address

1915 PARK CREST DR
CARDIFF BY THE SEA CA
92007-1427
US

V. Phone/Fax

Practice location:
  • Phone: 818-298-1461
  • Fax:
Mailing address:
  • Phone: 818-298-1461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number19334
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number19334
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number19334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: