Provider Demographics
NPI:1528699824
Name:THEOBALD, AMANDA LEE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 KINGMAN CT
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-9022
Mailing Address - Country:US
Mailing Address - Phone:740-359-6129
Mailing Address - Fax:
Practice Address - Street 1:170 TAYLOR STATION RD STE 220
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-4491
Practice Address - Country:US
Practice Address - Phone:614-866-8158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT006819225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist