Provider Demographics
NPI:1184732752
Name:KEASTER, AMANDA ELLISHA (OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELLISHA
Last Name:KEASTER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. DRAWER 2109
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-2109
Mailing Address - Country:US
Mailing Address - Phone:479-967-2322
Mailing Address - Fax:479-967-2876
Practice Address - Street 1:920 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-4303
Practice Address - Country:US
Practice Address - Phone:479-967-2322
Practice Address - Fax:479-967-2876
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2066225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR662725OtherHEALTHLINK
AR162765721Medicaid
AR5A030OtherBLUE CROSS BLUE SHIELD
AR5A030Medicare ID - Type Unspecified