Provider Demographics
NPI:1609313154
Name:BEAVER, AMY R (COTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:BEAVER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:768 ALDRO RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7825
Mailing Address - Country:US
Mailing Address - Phone:715-781-7189
Mailing Address - Fax:
Practice Address - Street 1:768 ALDRO RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7825
Practice Address - Country:US
Practice Address - Phone:715-781-7189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5333-27224Z00000X
MN202198224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant