Provider Demographics
NPI:1336911700
Name:MA, AMANDA (OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MA
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 1:11876 HOLLIS CT
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6754
Mailing Address - Country:US
Mailing Address - Phone:949-599-5707
Mailing Address - Fax:
Practice Address - Street 1:275 W HOSPITALITY LN STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3238
Practice Address - Country:US
Practice Address - Phone:909-567-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-27
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24969225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist