=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447713714
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA O. BAKER OTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2019
-----------------------------------------------------
Last Update Date | 04/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5223 VICTORIA ST NW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24017-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-986-6882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5233 VICTORIA ST NW
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24017-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-986-6882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 0131000387
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------