Healthcare Provider Details

I. General information

NPI: 1992362818
Provider Name (Legal Business Name): AMANDA BLACK MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 ELM ST
POTLATCH ID
83855
US

IV. Provider business mailing address

1026 GRANGE PARK RD
PRINCETON ID
83857-5500
US

V. Phone/Fax

Practice location:
  • Phone: 208-669-3186
  • Fax: 208-747-0782
Mailing address:
  • Phone: 208-669-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-1112
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-1112
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: