Healthcare Provider Details

I. General information

NPI: 1366078107
Provider Name (Legal Business Name): AMANDA HALKS MOT R/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5406 HOOVER BLVD STE 21
TAMPA FL
33634-5330
US

IV. Provider business mailing address

6401 NIKKI LN
TAMPA FL
33625-1641
US

V. Phone/Fax

Practice location:
  • Phone: 813-248-8149
  • Fax:
Mailing address:
  • Phone: 352-359-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT15458
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: