Provider Demographics
NPI:1518055763
Name:MARTIN, AMANDA SUE (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:SUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:SUE
Other - Last Name:KENNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7425 NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-993-7585
Mailing Address - Fax:618-998-9993
Practice Address - Street 1:3111 WILLIAMSON COUNTY PARKWAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant