Healthcare Provider Details

I. General information

NPI: 1417402454
Provider Name (Legal Business Name): AMANDA WALRATH O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MCDONNELL O.T.

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 S BOSTON AVE
TULSA OK
74119-4015
US

IV. Provider business mailing address

1519 S BOSTON AVE
TULSA OK
74119-4015
US

V. Phone/Fax

Practice location:
  • Phone: 918-949-9871
  • Fax:
Mailing address:
  • Phone: 918-949-9871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number082868
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: