Individual
AMANDA BLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MOT, OTR/L
Contact information
Practice address
510 ELM ST, POTLATCH, ID 83855
(208) 669-3186
(208) 747-0782
Mailing address
1026 GRANGE PARK RD, PRINCETON, ID 83857-5500
(208) 669-3186
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT-1112
ID
225XP0200X
Pediatric Occupational Therapist
OT-1112
ID
Other
Enumeration date
05/27/2019
Last updated
04/08/2022
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