Provider Demographics
NPI:1982395299
Name:GRUBB, AMANDA MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:GRUBB
Suffix:
Gender:F
Credentials:COTA
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 83
Mailing Address - Street 2:
Mailing Address - City:MARK CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43536-0083
Mailing Address - Country:US
Mailing Address - Phone:574-732-7895
Mailing Address - Fax:
Practice Address - Street 1:1400 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5832
Practice Address - Country:US
Practice Address - Phone:260-484-1558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003383A224Z00000X
OHOTA007230224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant