Provider Demographics
NPI:1518475755
Name:PODLESNIK, AMI MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:AMI
Middle Name:MARIE
Last Name:PODLESNIK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:AMI
Other - Middle Name:MARIE
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:14814 N 24TH DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-5079
Mailing Address - Country:US
Mailing Address - Phone:602-752-2665
Mailing Address - Fax:
Practice Address - Street 1:14814 N 24TH DR UNIT 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023
Practice Address - Country:US
Practice Address - Phone:602-752-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5697224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant