Provider Demographics
NPI:1659541217
Name:BLACK, AMIE (OTR)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:BLACK
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 1:8519 N CAPITAL OF TEXAS HWY
Mailing Address - Street 2:APT. 1040
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6001 W WILLIAM CANNON DR
Practice Address - Street 2:SUITE 304
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1968
Practice Address - Country:US
Practice Address - Phone:512-394-0735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103719225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist