Provider Demographics
NPI:1366921553
Name:HENDRICKS, AMANDA RAE (LMT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RAE
Last Name:HENDRICKS
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:P.O. BOX 5
Mailing Address - Street 2:601 E. COURT ST
Mailing Address - City:CONDON
Mailing Address - State:OR
Mailing Address - Zip Code:97823
Mailing Address - Country:US
Mailing Address - Phone:503-707-7400
Mailing Address - Fax:
Practice Address - Street 1:601 E. COURT ST
Practice Address - Street 2:
Practice Address - City:CONDON
Practice Address - State:OR
Practice Address - Zip Code:97823
Practice Address - Country:US
Practice Address - Phone:503-707-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLMT023660225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist