Provider Demographics
NPI:1407284805
Name:FLAVIN, AMBER (COTA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:FLAVIN
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 1:550 S MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2511
Mailing Address - Country:US
Mailing Address - Phone:815-399-4989
Mailing Address - Fax:
Practice Address - Street 1:550 S MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2511
Practice Address - Country:US
Practice Address - Phone:815-399-4989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003428224Z00000X
WI488727224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant