Provider Demographics
NPI:1497955769
Name:OLDERBAK, AMY M (OT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:OLDERBAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N HIAWATHA DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:SD
Mailing Address - Zip Code:57013
Mailing Address - Country:US
Mailing Address - Phone:605-987-2621
Mailing Address - Fax:
Practice Address - Street 1:440 N HIAWATHA DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:SD
Practice Address - Zip Code:57013
Practice Address - Country:US
Practice Address - Phone:605-987-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0651225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist