Healthcare Provider Details

I. General information

NPI: 1578947495
Provider Name (Legal Business Name): AMANDA CHRISTINE ANDERSON PT, DPT, MS, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 BRYAN ST # 140
DALLAS TX
75204-6724
US

IV. Provider business mailing address

4214 SWISS AVE UNIT B
DALLAS TX
75204-6676
US

V. Phone/Fax

Practice location:
  • Phone: 972-914-9204
  • Fax:
Mailing address:
  • Phone: 716-338-3734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1269492
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0003351
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1269492
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: