Healthcare Provider Details

I. General information

NPI: 1285003731
Provider Name (Legal Business Name): AMY M THIBODEAUX OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 KEPLER DR
GREEN BAY WI
54311-8321
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5500
  • Fax: 920-288-5510
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2801-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: