Provider Demographics
NPI:1841401346
Name:OLIVER, AMY B (OT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:OLIVER
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:PO BOX 13861
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3861
Mailing Address - Country:US
Mailing Address - Phone:601-853-9747
Mailing Address - Fax:601-898-4761
Practice Address - Street 1:665 HIGHWAY 51 STE C
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2136
Practice Address - Country:US
Practice Address - Phone:601-853-9747
Practice Address - Fax:601-898-4761
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126577Medicaid
MS06081560OtherMEDICAID GROUP #