Healthcare Provider Details

I. General information

NPI: 1316159171
Provider Name (Legal Business Name): AMANDA GALE BLADE O.T.R.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 CAMPBELL ST
VALPARAISO IN
46385-2363
US

IV. Provider business mailing address

1461 JADE BLVD
VALPARAISO IN
46385-6302
US

V. Phone/Fax

Practice location:
  • Phone: 219-462-1023
  • Fax:
Mailing address:
  • Phone: 219-548-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31004268A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: