=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679931513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY NOONAN MS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2016
-----------------------------------------------------
Last Update Date | 08/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 NW HARRIMAN ST
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97703-1977
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-322-7500
-----------------------------------------------------
Fax | 541-322-7565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2577 NE COURTNEY DR
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97701-7752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-322-7500
-----------------------------------------------------
Fax | 541-322-7565
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XN1300X
-----------------------------------------------------
Taxonomy Name | Neurorehabilitation Occupational Therapist
-----------------------------------------------------
License Number | OT 60430251
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 316047
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------