Healthcare Provider Details

I. General information

NPI: 1710929096
Provider Name (Legal Business Name): AMY K. VALLEJO O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY K. FORSYTH OT

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD THE HAND CENTER
MILWAUKEE WI
53226-3462
US

IV. Provider business mailing address

1155 N MAYFAIR RD THE HAND CENTER
MILWAUKEE WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-4263
  • Fax: 414-955-6286
Mailing address:
  • Phone: 414-955-4263
  • Fax: 414-955-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4007-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: