Provider Demographics
NPI:1194133785
Name:POTTS, AMANDA (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:POTTS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 DONNA AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60505-1074
Mailing Address - Country:US
Mailing Address - Phone:815-600-5220
Mailing Address - Fax:
Practice Address - Street 1:3845 MCCOY DR
Practice Address - Street 2:#105
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-4428
Practice Address - Country:US
Practice Address - Phone:630-499-2583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-26
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.015437225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist