Provider Demographics
NPI:1396098463
Name:CANTRELL, AMBER JEAN (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:JEAN
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:MS
Other - First Name:AMBER
Other - Middle Name:JEAN
Other - Last Name:ROGERES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS/OTR/L
Mailing Address - Street 1:4640 MARTIN RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5571
Mailing Address - Country:US
Mailing Address - Phone:678-679-1261
Mailing Address - Fax:678-679-1265
Practice Address - Street 1:4640 MARTIN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5571
Practice Address - Country:US
Practice Address - Phone:678-679-1261
Practice Address - Fax:678-679-1265
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005575225X00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003128747AMedicaid