Provider Demographics
NPI:1235653163
Name:WALESH, AMANDA M (COTA, CLT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:WALESH
Suffix:
Gender:F
Credentials:COTA, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HOLSTEIN
Mailing Address - State:WI
Mailing Address - Zip Code:53061-1210
Mailing Address - Country:US
Mailing Address - Phone:920-579-0879
Mailing Address - Fax:
Practice Address - Street 1:2629 N 7TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4932
Practice Address - Country:US
Practice Address - Phone:920-551-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5310224Z00000X
WI5310-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant