Provider Demographics
NPI:1225202500
Name:HEISER, AMY M (OTR, MT)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:M
Last Name:HEISER
Suffix:
Gender:F
Credentials:OTR, MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 E LE CAPITAINE CIR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-5158
Mailing Address - Country:US
Mailing Address - Phone:920-819-2555
Mailing Address - Fax:
Practice Address - Street 1:348 E LE CAPITAINE CIR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-5158
Practice Address - Country:US
Practice Address - Phone:920-819-2555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3701-46225700000X
WI6148-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41054900Medicaid