Basic Information
| Provider Information | |||||||||
| NPI: | 1427665264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GODWIN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTD, OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BERRYHILL | ||||||||
| OtherFirstName: | AMANDA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 43RD AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612658401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097432070 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2109 CEDARWOOD DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MUSCATINE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527612670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5632630557 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2020 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 098221 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 056013268 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.