Provider Demographics
NPI:1063959807
Name:BARTLETT, AMANDA (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BARTLETT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1546 GOLDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-3322
Mailing Address - Country:US
Mailing Address - Phone:310-430-8634
Mailing Address - Fax:
Practice Address - Street 1:1546 GOLDEN AVE
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-3322
Practice Address - Country:US
Practice Address - Phone:310-430-8634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist