Provider Demographics
NPI:1881800134
Name:BROTCKE, AMY BETH (OTR)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:BETH
Last Name:BROTCKE
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:W3370 W. NEDA RD
Mailing Address - Street 2:
Mailing Address - City:HORICON
Mailing Address - State:WI
Mailing Address - Zip Code:53032
Mailing Address - Country:US
Mailing Address - Phone:920-387-2237
Mailing Address - Fax:
Practice Address - Street 1:305 S CLARK ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1488
Practice Address - Country:US
Practice Address - Phone:920-387-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2906-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40841000Medicaid