Provider Demographics
NPI:1366862351
Name:AMUNDSON, MICHAEL JOSEPH (COTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:AMUNDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:MIMBRES
Mailing Address - State:NM
Mailing Address - Zip Code:88049-0078
Mailing Address - Country:US
Mailing Address - Phone:575-536-2958
Mailing Address - Fax:575-536-2958
Practice Address - Street 1:50 CHAMISA ROAD.
Practice Address - Street 2:
Practice Address - City:MIMBRES
Practice Address - State:NM
Practice Address - Zip Code:88049-0078
Practice Address - Country:US
Practice Address - Phone:575-536-2958
Practice Address - Fax:575-536-2958
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2773224Z00000X
TX211132224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant