Provider Demographics
NPI:1831284017
Name:WICKENKAMP, AMANDA (OTR)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:WICKENKAMP
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-534-9553
Mailing Address - Fax:720-932-8815
Practice Address - Street 1:1515 WAZEE STREET
Practice Address - Street 2:SUITE D
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1478
Practice Address - Country:US
Practice Address - Phone:303-534-9553
Practice Address - Fax:720-932-8815
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004359A225X00000X, 225XH1200X
OR1072823225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200837250Medicaid
IN156524Medicare PIN