Healthcare Provider Details

I. General information

NPI: 1720554157
Provider Name (Legal Business Name): AMY WADAGA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SPRING ST SE
GAINESVILLE GA
30501-3773
US

IV. Provider business mailing address

500 SPRING ST SE
GAINESVILLE GA
30501-3773
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-7676
  • Fax:
Mailing address:
  • Phone: 770-615-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT008769
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: