=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316159171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA GALE BLADE O.T.R.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3405 CAMPBELL ST
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46385-2363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-462-1023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1461 JADE BLVD
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46385-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-548-2450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 31004268A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------