Provider Demographics
NPI:1255383329
Name:CHEETHAM, AMY L (OT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:CHEETHAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 E JOLLY RD
Mailing Address - Street 2:STE 210
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6818
Mailing Address - Country:US
Mailing Address - Phone:517-346-8410
Mailing Address - Fax:517-346-8291
Practice Address - Street 1:812 E JOLLY RD
Practice Address - Street 2:STE 216
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910
Practice Address - Country:US
Practice Address - Phone:517-346-9515
Practice Address - Fax:517-346-8291
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist