Provider Demographics
NPI:1881941052
Name:WILSON, AMANDA K (OT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:K
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:411 W AGENCY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1704
Mailing Address - Country:US
Mailing Address - Phone:319-752-7727
Mailing Address - Fax:319-752-7774
Practice Address - Street 1:411 W AGENCY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1704
Practice Address - Country:US
Practice Address - Phone:319-752-7727
Practice Address - Fax:319-752-7774
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002236225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist