Provider Demographics
NPI:1366503948
Name:EAST, AMY (OTD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:EAST
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 MULL RDG
Mailing Address - Street 2:
Mailing Address - City:EPWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30541-2250
Mailing Address - Country:US
Mailing Address - Phone:706-632-3185
Mailing Address - Fax:706-632-9756
Practice Address - Street 1:3798 E FIRST ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4514
Practice Address - Country:US
Practice Address - Phone:706-632-7168
Practice Address - Fax:706-632-9756
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003884225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT003884OtherGA OT LICENSE
GA116855Medicare ID - Type Unspecified