Provider Demographics
NPI:1952421117
Name:MARCOTT, AMY L (MAED)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:MARCOTT
Suffix:
Gender:F
Credentials:MAED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 CALLON STREET
Mailing Address - Street 2:PO BOX 1702
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54402-1702
Mailing Address - Country:US
Mailing Address - Phone:715-845-5493
Mailing Address - Fax:
Practice Address - Street 1:1202 CALLON ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54402-1702
Practice Address - Country:US
Practice Address - Phone:715-845-5493
Practice Address - Fax:715-848-5645
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3223101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40937300Medicaid