Provider Demographics
NPI:1194478784
Name:VACCARO, AMANDA (OTR)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:VACCARO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4066 SENECA DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-0826
Mailing Address - Country:US
Mailing Address - Phone:575-642-2188
Mailing Address - Fax:
Practice Address - Street 1:1005 LUJAN HILL RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-6304
Practice Address - Country:US
Practice Address - Phone:575-523-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-02
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
NMOT4552225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator