Provider Demographics
NPI:1710929096
Name:VALLEJO, AMY K (OT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:VALLEJO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:K
Other - Last Name:FORSYTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:THE HAND CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-4263
Mailing Address - Fax:414-955-6286
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:THE HAND CENTER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-4263
Practice Address - Fax:414-955-6286
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4007-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40878600Medicaid
WIP00627733OtherRR MEDICARE
WI1710929096Medicaid
WI01994-0342Medicare PIN
WIP00627733OtherRR MEDICARE
WI000783880Medicare ID - Type Unspecified
WI40878600Medicaid
WI46236-0341Medicare PIN