Provider Demographics
NPI:1194121251
Name:VANDAVEER, AMY (COTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:VANDAVEER
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 1:3105 BLUFF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-3529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLE CAMP
Practice Address - State:MO
Practice Address - Zip Code:65325-1144
Practice Address - Country:US
Practice Address - Phone:660-668-4515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014003564224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant