Healthcare Provider Details

I. General information

NPI: 1851597983
Provider Name (Legal Business Name): AMANDA LYNN KETELSEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11210 95TH ST
COAL VALLEY IL
61240-9360
US

IV. Provider business mailing address

26535 225TH ST
LECLAIRE IA
52753-9720
US

V. Phone/Fax

Practice location:
  • Phone: 309-799-3161
  • Fax:
Mailing address:
  • Phone: 563-289-2076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number01734
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: