Provider Demographics
NPI:1861875890
Name:SMITH, AMBER DAWN (COTA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:DAWN
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:52565 STATE ROAD 933
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3257
Mailing Address - Country:US
Mailing Address - Phone:574-213-4721
Mailing Address - Fax:
Practice Address - Street 1:52565 STATE ROAD 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3257
Practice Address - Country:US
Practice Address - Phone:574-247-7044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32002152A224Z00000X
MI5202007559224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant