Provider Demographics
NPI:1811222763
Name:CULLISON, AMANDA TAYLOR (COTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:TAYLOR
Last Name:CULLISON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEIGH
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:11880 GREENVILLE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-0587
Mailing Address - Country:US
Mailing Address - Phone:214-349-6178
Mailing Address - Fax:
Practice Address - Street 1:11880 GREENVILLE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-0587
Practice Address - Country:US
Practice Address - Phone:214-349-6178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX403735224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant