Healthcare Provider Details

I. General information

NPI: 1720754377
Provider Name (Legal Business Name): AMY JANELLE SMITH OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 LEO ST
DAYTON OH
45404-1700
US

IV. Provider business mailing address

4801 SPRINGFIELD ST
DAYTON OH
45431-1084
US

V. Phone/Fax

Practice location:
  • Phone: 937-542-6130
  • Fax:
Mailing address:
  • Phone: 937-241-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-6390
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: