Provider Demographics
NPI:1578222196
Name:AVERY, AMANDA (OTR)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11A ELY RD
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-1405
Mailing Address - Country:US
Mailing Address - Phone:914-960-8485
Mailing Address - Fax:
Practice Address - Street 1:2201 MOUNT ZION PKWY
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-3312
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT008300225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist