Provider Demographics
NPI:1992257281
Name:CLARK, AMANDA (COTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CLARK
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 1:7146 BAHNE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37062-8207
Mailing Address - Country:US
Mailing Address - Phone:615-418-5498
Mailing Address - Fax:
Practice Address - Street 1:7146 BAHNE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062
Practice Address - Country:US
Practice Address - Phone:615-418-5498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16750224Z00000X
COOTA.0001097224Z00000X
MTOTP-OTA-LIC-6114224Z00000X
TN2598224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant