Healthcare Provider Details

I. General information

NPI: 1023947389
Provider Name (Legal Business Name): AMANDA LEE BOECKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 W IDLEWILD CT
GREEN BAY WI
54303-6566
US

IV. Provider business mailing address

2146 LUXURY DR
SUAMICO WI
54313-3226
US

V. Phone/Fax

Practice location:
  • Phone: 920-662-9700
  • Fax:
Mailing address:
  • Phone: 920-562-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: