Provider Demographics
NPI:1477625424
Name:UTECHT, AMY NICOLE (OTD, MSOT, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:NICOLE
Last Name:UTECHT
Suffix:
Gender:F
Credentials:OTD, MSOT, OTR/L
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:UTECHT
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTD, MSOT, OTR/L
Mailing Address - Street 1:709 CRESCENT CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4772
Mailing Address - Country:US
Mailing Address - Phone:678-462-1342
Mailing Address - Fax:678-493-9464
Practice Address - Street 1:2001 PROFESSIONAL PKWY STE 220
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6444
Practice Address - Country:US
Practice Address - Phone:448-543-8437
Practice Address - Fax:844-471-3799
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003834225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA490456055AOtherPEACH STATE HEALTH PLAN
GA10035969OtherAMERIGROUP
GA312668OtherWELLCARE
GA490456055DMedicaid
GA52070551 009OtherBLUE CROSS BLUE SHIELD
GA52070551 010OtherBLUE CROSS BLUE SHIELD
GA490456055AMedicaid
GA52070551 004OtherBLUE CROSS BLUE SHIELD