Provider Demographics
NPI:1821558511
Name:WISE, AMBER (COTA/L)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W SCREVEN ST
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-3913
Mailing Address - Country:US
Mailing Address - Phone:229-263-9100
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:1901 W SCREVEN ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-3913
Practice Address - Country:US
Practice Address - Phone:229-263-9100
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA002524224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant