Provider Demographics
NPI:1902065139
Name:PETKER, AMANDA A (OT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:A
Last Name:PETKER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 S ANDERSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:ELWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46036-2015
Mailing Address - Country:US
Mailing Address - Phone:765-552-8460
Mailing Address - Fax:765-552-8470
Practice Address - Street 1:226 S ANDERSON ST STE B
Practice Address - Street 2:
Practice Address - City:ELWOOD
Practice Address - State:IN
Practice Address - Zip Code:46036-2015
Practice Address - Country:US
Practice Address - Phone:765-552-8460
Practice Address - Fax:765-552-8470
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004646A225X00000X, 225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00702440OtherRR MEDICARE
IN062110I9Medicare PIN
INP00702440OtherRR MEDICARE