Provider Demographics
NPI:1265912950
Name:HARRISON, AMANDA GRACE (OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:HARRISON
Suffix:
Gender:F
Credentials: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:PO BOX 1637
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-1637
Mailing Address - Country:US
Mailing Address - Phone:615-382-0500
Mailing Address - Fax:615-382-0501
Practice Address - Street 1:514 S BROWN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2937
Practice Address - Country:US
Practice Address - Phone:615-382-0500
Practice Address - Fax:615-382-0501
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6023225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038378Medicaid