Provider Demographics
NPI:1760662027
Name:RICHARDSON, AMANDA (HIS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:140 CORPORATE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-1281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:920-887-9655
Practice Address - Street 1:N87 W16459 B WEST APPLETON
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-502-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1174-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42834200Medicaid