Provider Demographics
NPI:1104639806
Name:AMERSON, MARK BLAIRE (OTR)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:BLAIRE
Last Name:AMERSON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5651 LAKE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3969
Mailing Address - Country:US
Mailing Address - Phone:205-515-2393
Mailing Address - Fax:
Practice Address - Street 1:203 S SANTA CLAUS LN # 4
Practice Address - Street 2:
Practice Address - City:NORTH POLE
Practice Address - State:AK
Practice Address - Zip Code:99705-7711
Practice Address - Country:US
Practice Address - Phone:907-887-1697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-28
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK234140225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist