Provider Demographics
NPI:1194087056
Name:MEYERS BROUGHTON, AMANDA (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MEYERS BROUGHTON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MEYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:865 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-1264
Mailing Address - Country:US
Mailing Address - Phone:309-649-1572
Mailing Address - Fax:
Practice Address - Street 1:865 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-1264
Practice Address - Country:US
Practice Address - Phone:309-649-1572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005459225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant