Provider Demographics
NPI:1285293258
Name:CARRILLO, AMANDA ASHLEY (COTA/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ASHLEY
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2613 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8623
Mailing Address - Country:US
Mailing Address - Phone:575-749-9524
Mailing Address - Fax:
Practice Address - Street 1:3200 MISSION ARCH DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-8307
Practice Address - Country:US
Practice Address - Phone:575-624-2583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOTA2852224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant