Basic Information
| Provider Information | |||||||||
| NPI: | 1811292162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLER | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | P.T.D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105358180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 130 HOSPITAL RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105358180 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 01/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23508 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 406409700 | 05 | MD | MEDICAID |