Healthcare Provider Details

I. General information

NPI: 1780128124
Provider Name (Legal Business Name): AMBER KIECK OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 S 90TH ST
WEST ALLIS WI
53227-2455
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-321-2255
  • Fax: 414-321-2091
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number4736-26
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4736
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: