MEDICARE: AMANDA TILSTRA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5577	SC

General Provider Information

NPI Number	:	1073174231
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA TILSTRA

Provider Business Mailing Address
First Line	:	3064 BRIDGEWATER ST
Second Line	:
City	:	LANCASTER
State	:	SC
Zip	:	29720-0249
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3064 BRIDGEWATER ST
Second Line	:
City	:	LANCASTER
State	:	SC
Zip	:	29720-0249
Country	:	US
Telephone Number	:	845-542-0128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2019
Last Update Date	:	05/14/2026

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