Provider Demographics
NPI:1306166459
Name:BUSSELLE, AMANDA R (PTA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:R
Last Name:BUSSELLE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4802
Mailing Address - Country:US
Mailing Address - Phone:501-279-9255
Mailing Address - Fax:501-279-9257
Practice Address - Street 1:2918 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4802
Practice Address - Country:US
Practice Address - Phone:501-279-9255
Practice Address - Fax:501-279-9257
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant