Provider Demographics
NPI:1386274207
Name:PHILLIPS, AMANDA LEIGH (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:PHILLIPS
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 1:30 RANCHO DR N
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-5005
Mailing Address - Country:US
Mailing Address - Phone:817-266-4922
Mailing Address - Fax:
Practice Address - Street 1:1925 GOLDEN HEIGHTS RD STE 108
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76177-7074
Practice Address - Country:US
Practice Address - Phone:817-266-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT127746225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist