=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073095725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA C OWENS COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2018
-----------------------------------------------------
Last Update Date | 08/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 N FRANCES ST
-----------------------------------------------------
City | TERRELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75160-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-524-2503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1968 OBSIDIAN TRL
-----------------------------------------------------
City | HEARTLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75126-1160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-421-1464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 213470
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------