Provider Demographics
NPI:1316002991
Name:CEDILLO, AMANDA GRACE (OTR L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:CEDILLO
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 LAKE BOONE TRAIL
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7511
Mailing Address - Country:US
Mailing Address - Phone:919-781-4434
Mailing Address - Fax:919-781-5851
Practice Address - Street 1:4201 LAKE BOONE TRAIL
Practice Address - Street 2:SUITE 4
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7511
Practice Address - Country:US
Practice Address - Phone:919-781-4434
Practice Address - Fax:919-781-5851
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
NC5919225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
187639OtherMEDCOST
7404775OtherAETNA
1413TOtherBCBS
6400040OtherUNITED HEATHCARE
NC7301902Medicaid
NC8300041KMedicaid