Provider Demographics
NPI:1942597877
Name:KEGG, AMANDA M (COTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:KEGG
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2620 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-2841
Mailing Address - Country:US
Mailing Address - Phone:260-241-6240
Mailing Address - Fax:
Practice Address - Street 1:5202 SAINT JOE RD
Practice Address - Street 2:SUITE 340
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3380
Practice Address - Country:US
Practice Address - Phone:260-485-6068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001579A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant