Amanda Black, MOT, OTR/L

Primary specialty

Occupational TherapistTaxonomy code 225X00000X

License

OT-1112 Issued in ID

Practice address

510 Elm St
Potlatch, ID 83855

Phone

(208) 669-3186

Fax

(208) 747-0782

NPI assigned

May 27, 2019

Last updated

Apr 8, 2022By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in ID

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• BK Inc.

  dba Moscow Mountain Sport and Physical Therapy

  • Physical Therapy Clinic/Center
  • Moscow, ID
  • NPI 1659429405
  Medicare reassignment NPD
• Palouse Ridge Occupational Therapy PLLC

  • Pediatric Occupational Therapist
  • Potlatch, ID
  • NPI 1609518166

  Pediatrics

  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1558915200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1649376000000",
    "number": "1992362818",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1026 GRANGE PARK RD",
            "city": "PRINCETON",
            "state": "ID",
            "postal_code": "838575500",
            "telephone_number": "208-669-3186"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "510 ELM ST",
            "city": "POTLATCH",
            "state": "ID",
            "postal_code": "83855",
            "telephone_number": "208-669-3186",
            "fax_number": "208-747-0782"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "904 White Ave",
            "address_purpose": "LOCATION",
            "city": "Moscow",
            "state": "ID",
            "postal_code": "838433932",
            "country_code": "US",
            "telephone_number": "208-882-1426",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BLACK",
        "first_name": "AMANDA",
        "credential": "MOT, OTR/L",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2019-05-27",
        "last_updated": "2022-04-08",
        "certification_date": "2022-04-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225XP0200X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist, Pediatrics",
            "state": "ID",
            "license": "OT-1112",
            "primary": false
        },
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "ID",
            "license": "OT-1112",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Charlotte S Ainge, PAC
• Nicholas John Browneller
• County of Latah 285 School District
• Dan Lawson DDS, PC (Potlatch Family Dental)
• Michael Clyde Graham, P.A.
• Gritman Medical Center Inc (Potlatch Clinic)

• Occupational Therapist in Potlatch, ID
• Providers in Potlatch, ID by specialty
• Occupational Therapist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.