Provider Demographics
NPI:1336503853
Name:CRAIN, AMBERLY (COTA)
Entity Type:Individual
Prefix:
First Name:AMBERLY
Middle Name:
Last Name:CRAIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 TALONS TRL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6019
Mailing Address - Country:US
Mailing Address - Phone:601-940-5906
Mailing Address - Fax:601-510-9012
Practice Address - Street 1:5411 I 55 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3616
Practice Address - Country:US
Practice Address - Phone:601-940-5906
Practice Address - Fax:601-510-9012
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2715224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant