Healthcare Provider Details

I. General information

NPI: 1255495057
Provider Name (Legal Business Name): AMANDA JOANNE KEMNETZ MOT,OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 WILLIAM LATHAM DR SUITE 6A
BOURBONNAIS IL
60914-2327
US

IV. Provider business mailing address

40 E JOLIET ST SUITE A
SCHERERVILLE IN
46375-2054
US

V. Phone/Fax

Practice location:
  • Phone: 815-932-0381
  • Fax:
Mailing address:
  • Phone: 219-979-2735
  • Fax: 219-865-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number056-006344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: