Provider Demographics
NPI:1215692454
Name:BRADSHAW, AMY LYNNE (OTA)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LYNNE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-3305
Mailing Address - Country:US
Mailing Address - Phone:845-467-5201
Mailing Address - Fax:
Practice Address - Street 1:101 MANSION ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-2412
Practice Address - Country:US
Practice Address - Phone:845-451-4690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP112782224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant