Provider Demographics
NPI:1932422722
Name:MOODY, AMANDA (MS, OTR/L)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4673
Mailing Address - Street 2:763 BULL RUN
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-4673
Mailing Address - Country:US
Mailing Address - Phone:970-618-8303
Mailing Address - Fax:
Practice Address - Street 1:763 BULL RUN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-4673
Practice Address - Country:US
Practice Address - Phone:970-618-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2092225X00000X, 225XE0001X, 225XF0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & Swallowing