Provider Demographics
NPI:1104970235
Name:MEDEIROS, AMIE ANGELLE (OT)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:ANGELLE
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 SUMMERLAND KEY LN
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5152
Mailing Address - Country:US
Mailing Address - Phone:214-929-9495
Mailing Address - Fax:
Practice Address - Street 1:108 RUE LOUIS XIV
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5739
Practice Address - Country:US
Practice Address - Phone:337-889-3106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111421225X00000X
LAOTT.200364225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist