Provider Demographics
NPI:1255102471
Name:MCCORRY, AMANDA RENEE (COTA/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENEE
Last Name:MCCORRY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5356
Mailing Address - Country:US
Mailing Address - Phone:307-778-7550
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1145208100000X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation