Healthcare Provider Details

I. General information

NPI: 1164831582
Provider Name (Legal Business Name): AMANDA HARBAUGH ATC/LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2014
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E CLEVELAND AVE
MONETT MO
65708-1436
US

IV. Provider business mailing address

1005 9TH ST APT. B
MONETT MO
65708-1242
US

V. Phone/Fax

Practice location:
  • Phone: 417-236-2480
  • Fax:
Mailing address:
  • Phone: 417-872-8053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2011024429
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: