Provider Demographics
NPI:1053394445
Name:BABCOCK, AMY LYNN (PT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:BABCOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYNN
Other - Last Name:FOWLKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 PORTOLA RD
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7852
Mailing Address - Country:US
Mailing Address - Phone:650-851-1145
Mailing Address - Fax:650-851-9251
Practice Address - Street 1:150 PORTOLA RD
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7852
Practice Address - Country:US
Practice Address - Phone:650-851-1145
Practice Address - Fax:650-851-9251
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 26715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEO585ZMedicare PIN