Provider Demographics
NPI:1598962573
Name:ANDERSON, AMBER DESTINY (COTA)
Entity Type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:DESTINY
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 5TH ST W
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-3608
Mailing Address - Country:US
Mailing Address - Phone:205-384-3188
Mailing Address - Fax:
Practice Address - Street 1:2201 11TH AVE
Practice Address - Street 2:
Practice Address - City:HALEYVILLE
Practice Address - State:AL
Practice Address - Zip Code:35565-1613
Practice Address - Country:US
Practice Address - Phone:205-486-9478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2612224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant