Provider Demographics
NPI:1770005795
Name:ELLIS-CARPENTER, AMBER CHEREE (OT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:CHEREE
Last Name:ELLIS-CARPENTER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 GOODMAN RD E STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9504
Mailing Address - Country:US
Mailing Address - Phone:901-830-9899
Mailing Address - Fax:
Practice Address - Street 1:1890 GOODMAN RD E STE 201
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9504
Practice Address - Country:US
Practice Address - Phone:901-830-9899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2256225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty