Healthcare Provider Details

I. General information

NPI: 1891191714
Provider Name (Legal Business Name): AMANDA NEUROHR OTR, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 1ST ST
SPRING VALLEY IL
61362-1512
US

IV. Provider business mailing address

609 MILL ST
UTICA IL
61373-9402
US

V. Phone/Fax

Practice location:
  • Phone: 815-223-5346
  • Fax:
Mailing address:
  • Phone: 815-830-4717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003017
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.011267
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: