Provider Demographics
NPI:1669868899
Name:DICKERSON, AMANDA (COTA/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:802 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:217 E CHERRY AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3372
Practice Address - Country:US
Practice Address - Phone:870-932-5551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A947224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant