Provider Demographics
NPI:1518560226
Name:HRISTOV, AMY M (COTA/L)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:HRISTOV
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 S BEECH AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3404
Mailing Address - Country:US
Mailing Address - Phone:918-728-1596
Mailing Address - Fax:
Practice Address - Street 1:6636 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-3247
Practice Address - Country:US
Practice Address - Phone:918-357-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1878224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant