Healthcare Provider Details

I. General information

NPI: 1306276514
Provider Name (Legal Business Name): AMY WISE OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY CALLANAN OTR/L

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EXECUTIVE PARKWAY DR
SAINT LOUIS MO
63141-6325
US

IV. Provider business mailing address

1000 EXECUTIVE PARKWAY DR STE 120
SAINT LOUIS MO
63141-6369
US

V. Phone/Fax

Practice location:
  • Phone: 314-828-1443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2013029780
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: