Basic Information
| Provider Information | |||||||||
| NPI: | 1831268176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKMON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 NORTHEAST EXPY NE | ||||||||
| Address2: | BUILDING 8, SUITE C | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303413932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705003848 | ||||||||
| FaxNumber: | 6788681114 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 NORTHEAST EXPY NE | ||||||||
| Address2: | BUILDING 8, SUITE C | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303413932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705003848 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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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 | PT008401 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT008401 | 01 | GA | STATE LISC NUMBER | OTHER |