Provider Demographics
NPI:1588075113
Name:SCHMIDT, AMANDA (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7026
Mailing Address - Country:US
Mailing Address - Phone:530-543-5896
Mailing Address - Fax:530-544-6512
Practice Address - Street 1:2170 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-7026
Practice Address - Country:US
Practice Address - Phone:530-543-5896
Practice Address - Fax:530-544-6512
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60328305225200000X
COPTA.0012515225200000X
CA10917225200000X
NVA-0798225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant