Healthcare Provider Details

I. General information

NPI: 1396917167
Provider Name (Legal Business Name): AMANDA D'LAYNE PHILLIPS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N KENTUCKY AVE
ROSWELL NM
88201-4636
US

IV. Provider business mailing address

214 BLUE MOUNTAIN RD
ROSWELL NM
88201-9407
US

V. Phone/Fax

Practice location:
  • Phone: 806-470-2901
  • Fax:
Mailing address:
  • Phone: 806-470-2901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2443
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: