=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205546561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY ELIZABETH HODEL OTD, OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2022
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1550 MIDWAY PL
-----------------------------------------------------
City | MENASHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54952-1165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-738-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11109 PARKVIEW PLAZA DR # 117
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46845-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 31007779A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 8095-26
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------