Provider Demographics
NPI:1063785608
Name:CROUCH, AMANDA MARIE (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:GEALOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:2109 CEDARWOOD DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-2670
Mailing Address - Country:US
Mailing Address - Phone:563-288-6787
Mailing Address - Fax:563-288-6719
Practice Address - Street 1:2109 CEDARWOOD DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-2670
Practice Address - Country:US
Practice Address - Phone:563-288-6787
Practice Address - Fax:563-288-6719
Is Sole Proprietor?:No
Enumeration Date:2012-02-13
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004901225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA107205Medicaid