Provider Demographics
NPI:1184856833
Name:STODDARD, AMY (COTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:STODDARD
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 1:5320 SCHLUTER RD
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3018
Mailing Address - Country:US
Mailing Address - Phone:608-770-6732
Mailing Address - Fax:
Practice Address - Street 1:5979 SIGGELKOW RD
Practice Address - Street 2:
Practice Address - City:MC FARLAND
Practice Address - State:WI
Practice Address - Zip Code:53558-9817
Practice Address - Country:US
Practice Address - Phone:608-838-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1911-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42255100Medicaid