Provider Demographics
NPI:1568651891
Name:KEEL ENDEMANN, AMBER S (COTA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:S
Last Name:KEEL ENDEMANN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:S
Other - Last Name:ENDEMANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:155 MARINA PL APT 312
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-4111
Mailing Address - Country:US
Mailing Address - Phone:920-475-2920
Mailing Address - Fax:
Practice Address - Street 1:3305 N BALLARD RD STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-9001
Practice Address - Country:US
Practice Address - Phone:920-735-9234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1928224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant