Provider Demographics
NPI:1053901835
Name:MERRELL, AMANDA GRACE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:MERRELL
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224-1609
Mailing Address - Country:US
Mailing Address - Phone:513-377-5408
Mailing Address - Fax:
Practice Address - Street 1:251 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314-8564
Practice Address - Country:US
Practice Address - Phone:513-377-5408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0062922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer