Provider Demographics
NPI:1992362818
Name:BLACK, AMANDA (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 GRANGE PARK RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:ID
Mailing Address - Zip Code:83857-5500
Mailing Address - Country:US
Mailing Address - Phone:208-669-3186
Mailing Address - Fax:
Practice Address - Street 1:510 ELM ST
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855
Practice Address - Country:US
Practice Address - Phone:208-669-3186
Practice Address - Fax:208-747-0782
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-27
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1112225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics