Provider Demographics
NPI:1669097135
Name:PROTHEROE, AMY LYNN (OTR)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:PROTHEROE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10265 GANDY BLVD N APT 1003
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2332
Mailing Address - Country:US
Mailing Address - Phone:407-733-1165
Mailing Address - Fax:
Practice Address - Street 1:2725 ROBIE AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-9619
Practice Address - Country:US
Practice Address - Phone:800-626-3876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20805225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty