Individual
MRS. AMANDA STREET
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OT
Contact information
Practice address
960 COMMONWEALTH BLVD, TUPELO, MS 38804-9762
(662) 260-3789
(662) 260-3790
Mailing address
PO BOX 822394, VICKSBURG, MS 39182-2394
(601) 638-4076
(601) 638-4979
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT1818
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000050976
BCBS
MS
05
—
05037726
—
MS
Enumeration date
01/05/2007
Last updated
06/08/2022
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