Provider Demographics
NPI:1295767325
Name:MCMAHON, AMY H (OT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:H
Last Name:MCMAHON
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 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-251-2100
Mailing Address - Fax:574-251-2150
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:SUITE 430
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-968-2851
Practice Address - Fax:574-968-2855
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004017A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200247530Medicaid
IN200247530Medicaid