=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316798010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMANDA BEVERLY LMT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2024
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 E NEW CIRCLE RD SUITE 160
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-309-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2552 CRUSADERS WAY
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-542-1586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | MS. AMANDA JANE BEVERLY
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 502-542-1586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------