Provider Demographics
NPI:1235474123
Name:FLAHERTY, AMY JEAN (MOTR)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:FLAHERTY
Suffix:
Gender:F
Credentials:MOTR
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JEAN
Other - Last Name:STORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:430 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-5390
Mailing Address - Fax:
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-5390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4835-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist