Provider Demographics
NPI:1558022871
Name:KOSS, AMANDA ROSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:KOSS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5243 PINE KNOB TRL
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4131
Mailing Address - Country:US
Mailing Address - Phone:586-899-6592
Mailing Address - Fax:
Practice Address - Street 1:5243 PINE KNOB TRL
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4131
Practice Address - Country:US
Practice Address - Phone:586-899-6592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201012662225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist