Provider Demographics
NPI:1720236490
Name:LANE, AMANDA DICKERSON (DPT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:DICKERSON
Last Name:LANE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3125 INDEPENDENCE DR
Mailing Address - Street 2:300B
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209
Mailing Address - Country:US
Mailing Address - Phone:205-879-7501
Mailing Address - Fax:205-879-0675
Practice Address - Street 1:975 9TH AVE SW STE 320
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-7839
Practice Address - Country:US
Practice Address - Phone:205-277-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL23663225100000X
ALPTH4985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL55#OtherTRICARE SOUTH REG.
ALDB3969OtherPALMELTO DBA RAIL ROAD MEDICARE
AL510I650199OtherMEDICARE PTAN
AL51593961OtherBLUE CROSS
ALA24734Medicare UPIN