Provider Demographics
NPI:1073104337
Name:GREEN, AMANDA LEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 NEW HOPE ROAD
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648
Mailing Address - Country:US
Mailing Address - Phone:740-464-4017
Mailing Address - Fax:740-876-4650
Practice Address - Street 1:381 CAMP ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN FURNACE
Practice Address - State:OH
Practice Address - Zip Code:45629-7503
Practice Address - Country:US
Practice Address - Phone:740-574-1315
Practice Address - Fax:740-876-4650
Is Sole Proprietor?:No
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007193224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant