MEDICARE: DR. AMY NICOLE UTECHT OTD, MSOT, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT003834	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	490456055A	OTHER	GA	PEACH STATE HEALTH PLAN
2	10035969	OTHER	GA	AMERIGROUP
3	312668	OTHER	GA	WELLCARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	52070551 009	OTHER	GA	BLUE CROSS BLUE SHIELD
6	52070551 010	OTHER	GA	BLUE CROSS BLUE SHIELD
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	52070551 004	OTHER	GA	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1477625424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY NICOLE UTECHT OTD, MSOT, OTR/L

Provider Business Mailing Address
First Line	:	709 CRESCENT CIR
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30115-4772
Country	:	US
Telephone Number	:	678-462-1342
Fax Number	:	678-493-9464

Provider Business Practice Location Address
First Line	:	2001 PROFESSIONAL PKWY STE 220
Second Line	:
City	:	WOODSTOCK
State	:	GA
Zip	:	30188-6444
Country	:	US
Telephone Number	:	448-543-8437
Fax Number	:	844-471-3799

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/16/2019

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