Healthcare Provider Details

I. General information

NPI: 1801458252
Provider Name (Legal Business Name): AMANDA DAWN TEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA DAWN DREW PT

II. Dates (important events)

Enumeration Date: 07/06/2019
Last Update Date: 07/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 KING ST
NORTHAMPTON MA
01060-3234
US

IV. Provider business mailing address

131 KING ST
NORTHAMPTON MA
01060-3234
US

V. Phone/Fax

Practice location:
  • Phone: 413-665-8717
  • Fax: 413-665-9383
Mailing address:
  • Phone: 413-665-8717
  • Fax: 413-665-9383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2305210423
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: