Healthcare Provider Details

I. General information

NPI: 1265868756
Provider Name (Legal Business Name): AMANDA ZACHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA HOFFMAN

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 BALSON AVE.
ST. LOUIS MO
63130
US

IV. Provider business mailing address

310 STEEPLE LN
WILDWOOD MO
63005-4202
US

V. Phone/Fax

Practice location:
  • Phone: 618-420-5906
  • Fax:
Mailing address:
  • Phone: 186-420-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056.010257
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2021019935
License Number StateMO

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: