Provider Demographics
NPI:1467666867
Name:RICHARDSON, AMY (OTR)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W245S7390 HEATHER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9361
Mailing Address - Country:US
Mailing Address - Phone:414-731-0568
Mailing Address - Fax:
Practice Address - Street 1:W231S7680 BIG BEND DR
Practice Address - Street 2:
Practice Address - City:BIG BEND
Practice Address - State:WI
Practice Address - Zip Code:53103-9686
Practice Address - Country:US
Practice Address - Phone:262-662-9760
Practice Address - Fax:262-662-9761
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4521026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41045600Medicaid