=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740096320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA CERVANTES LMBT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6843 MONTANA ST
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28547-2558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-779-6771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6843 MONTANA ST
-----------------------------------------------------
City | CAMP LEJEUNE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28547-2558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-779-6771
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 22058
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------