Amanda Black, MOT, OTR/L
Individual provider Active NPI Occupational Therapist · Potlatch, ID
NPI 1992362818 · NPPES record last updated Apr 8, 2022
Key facts
- NPI
- 1992362818
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Occupational Therapist 225X00000X
- License
- OT-1112 (ID)
- Practice address
- 510 Elm St
Potlatch, ID 83855 - Phone
- (208) 669-3186
- Fax
- (208) 747-0782
- NPI assigned
- May 27, 2019
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in ID
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20190726001502 | ID | Practitioner - Occupational Therapist in Private Practice | 4789910852 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Palouse Ridge Occupational Therapy PLLC | Pediatrics | Current |
Accepting new patients |
| BK Inc. | Current |
Accepting new patients |
Locations
2009 S Main St
Moscow, ID 83843
Phone (208) 618-8430
904 White Ave
Moscow, ID 83843
Phone (208) 596-1056
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Occupational Therapist | 225XP0200X | OT-1112 | ID | |
| Occupational Therapist | 225X00000X | OT-1112 | ID | Yes |
Addresses
Primary practice location
510 Elm St
Potlatch, ID 83855
Mailing address
1026 Grange Park Rd
Princeton, ID 83857-5500
Phone (208) 669-3186
Other practice location 1
904 White Ave
Moscow, ID 83843-3932
Phone (208) 882-1426
Other providers in Potlatch, ID
- Charlotte S Ainge
- Nicholas John Browneller
- County of Latah 285 School District
- Dan Lawson DDS, PC
- Michael Clyde Graham
- Gritman Medical Center Inc
All providers in Potlatch, ID · Occupational Therapist in Idaho
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 8, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.