Provider Demographics
NPI:1831381094
Name:ENRICO, AMANDA CHEYENNE (OTR)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CHEYENNE
Last Name:ENRICO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 COBBLECREST RD
Mailing Address - Street 2:
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422
Mailing Address - Country:US
Mailing Address - Phone:208-709-2911
Mailing Address - Fax:
Practice Address - Street 1:30 E LITTLE AVE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5138
Practice Address - Country:US
Practice Address - Phone:208-709-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR719225X00000X
IDOT-835225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist