Provider Demographics
NPI:1871537381
Name:QUEEN, AMY L (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:QUEEN
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2812
Mailing Address - Country:US
Mailing Address - Phone:304-599-2515
Mailing Address - Fax:304-285-3738
Practice Address - Street 1:60 CLARKSBURG RD
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-8400
Practice Address - Country:US
Practice Address - Phone:304-472-0181
Practice Address - Fax:304-472-0192
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7304067000Medicaid
WV7304067000Medicaid