1477625424 NPI number — DR. AMY NICOLE UTECHT OTD, MSOT, OTR/L

Table of content: DR. AMY NICOLE UTECHT OTD, MSOT, OTR/L (NPI 1477625424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477625424 NPI number — DR. AMY NICOLE UTECHT OTD, MSOT, OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UTECHT
Provider First Name:
AMY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OTD, MSOT, OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
AMY
Provider Other Middle Name:
UTECHT
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTD, MSOT, OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477625424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 CRESCENT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30115-4772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-462-1342
Provider Business Mailing Address Fax Number:
678-493-9464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 PROFESSIONAL PKWY STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30188-6444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
448-543-8437
Provider Business Practice Location Address Fax Number:
844-471-3799
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT003834 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 490456055A . This is a "PEACH STATE HEALTH PLAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 10035969 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 312668 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 490456055D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52070551 009 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52070551 010 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 490456055A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52070551 004 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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