Provider Demographics
NPI:1144530478
Name:DODGE, AMANDA ELIZABETH (COTA/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:DODGE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-3251
Mailing Address - Country:US
Mailing Address - Phone:802-376-0021
Mailing Address - Fax:
Practice Address - Street 1:23 MAHAN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1315
Practice Address - Country:US
Practice Address - Phone:603-443-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT073.0044975224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant