Basic Information
| Provider Information | |||||||||
| NPI: | 1255881223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BAILY | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherCredential: | COTA/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1016 DOUGLAS CT | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370551661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157889820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 812 N CHARLOTTE ST | ||||||||
| Address2: | |||||||||
| City: | DICKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370551009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154468046 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2016 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 1236 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.