Provider Demographics
NPI:1700122256
Name:WALLER, AMANDA SHIRLEY (COTA/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SHIRLEY
Last Name:WALLER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:CASSADAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14718-9640
Mailing Address - Country:US
Mailing Address - Phone:716-474-5232
Mailing Address - Fax:
Practice Address - Street 1:50 EAST NORTH STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203
Practice Address - Country:US
Practice Address - Phone:716-885-8318
Practice Address - Fax:716-885-0229
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007631-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant