Provider Demographics
NPI:1043714629
Name:AMORESANO, ANGELO JR (OTR)
Entity type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:AMORESANO
Suffix:JR
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 SPINE RD UNIT 310
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3594
Mailing Address - Country:US
Mailing Address - Phone:239-745-5649
Mailing Address - Fax:
Practice Address - Street 1:5501 SPINE RD UNIT 310
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3594
Practice Address - Country:US
Practice Address - Phone:239-745-5649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0005297225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist