Provider Demographics
NPI:1366513186
Name:IRWIN, AMY ROSE (OTR)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:IRWIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 HARCOURT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3946
Mailing Address - Country:US
Mailing Address - Phone:740-392-8811
Mailing Address - Fax:740-392-6485
Practice Address - Street 1:351 S LANE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-2319
Practice Address - Country:US
Practice Address - Phone:419-562-6686
Practice Address - Fax:419-562-6625
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04787225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHIR4042124Medicare ID - Type Unspecified