Provider Demographics
NPI:1063037976
Name:BUSSAN, AMANDA (COTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BUSSAN
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 1:452 N BIRDSEY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1128
Mailing Address - Country:US
Mailing Address - Phone:608-444-8224
Mailing Address - Fax:
Practice Address - Street 1:198 COUNTY ROAD DF
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:WI
Practice Address - Zip Code:53039-9515
Practice Address - Country:US
Practice Address - Phone:920-386-3472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5700-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant