Provider Demographics
NPI:1992196224
Name:HOLMBERG, AMANDA J (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:J
Last Name:HOLMBERG
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 1:1248 S JOHN YOUNG PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-6389
Mailing Address - Country:US
Mailing Address - Phone:407-913-1010
Mailing Address - Fax:407-992-8697
Practice Address - Street 1:1248 S JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-6389
Practice Address - Country:US
Practice Address - Phone:407-913-1010
Practice Address - Fax:407-992-8697
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14019224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant