Provider Demographics
NPI:1205414505
Name:HOLSTED, AMANDA (COTA/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HOLSTED
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 1:413 S BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:CARNEGIE
Mailing Address - State:OK
Mailing Address - Zip Code:73015-9422
Mailing Address - Country:US
Mailing Address - Phone:405-234-6569
Mailing Address - Fax:
Practice Address - Street 1:753 FT. SILL BLVD.
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-1009
Practice Address - Country:US
Practice Address - Phone:580-357-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1125224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant