Provider Demographics
NPI:1629380167
Name:WILSON, AMIE L (OTR)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:AMIE
Other - Middle Name:L
Other - Last Name:JANZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:W7533 CHERRY HILL DR
Mailing Address - Street 2:
Mailing Address - City:ADELL
Mailing Address - State:WI
Mailing Address - Zip Code:53001-1294
Mailing Address - Country:US
Mailing Address - Phone:920-994-9495
Mailing Address - Fax:
Practice Address - Street 1:402 FIRST ST
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-0323
Practice Address - Country:US
Practice Address - Phone:920-994-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3556-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist