Provider Demographics
NPI:1053795963
Name:SMALL, AMBER (COTA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7182 CLAUDE AVE
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-2521
Practice Address - Country:US
Practice Address - Phone:435-654-8174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201989225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation