Provider Demographics
NPI:1275938474
Name:CLOUGH-KNAPP, AMANDA (OT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:CLOUGH-KNAPP
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:CLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:12500 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1227
Mailing Address - Country:US
Mailing Address - Phone:262-857-5800
Mailing Address - Fax:
Practice Address - Street 1:12500 AURORA DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1227
Practice Address - Country:US
Practice Address - Phone:262-857-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5549225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100049307Medicaid