Provider Demographics
NPI:1831468503
Name:ST.JOHN, AMY MICHELLE (COTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:ST.JOHN
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 1:135 KARL AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9700
Mailing Address - Country:US
Mailing Address - Phone:608-445-5620
Mailing Address - Fax:
Practice Address - Street 1:2448 SOUTH 102ND ST
Practice Address - Street 2:STE 340 MJ CARE INC
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227
Practice Address - Country:US
Practice Address - Phone:414-329-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4751-27224Z00000X
IL057003295224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant