Basic Information
| Provider Information | |||||||||
| NPI: | 1174539951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILMOT | ||||||||
| FirstName: | AMANDA | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Credential: | C.O.T.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | W9843 OLD 14 RD | ||||||||
| Address2: | |||||||||
| City: | LADYSMITH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548489516 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1016 LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | RICE LAKE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548681225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152349101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 1732-027 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1732-027 | 01 | WI | STATE OF WI CREDENTIALS | OTHER | 40875100 | 05 | WI | MEDICAID | 1044814 | 01 | WI | NATIONAL BOARD FOR CERT. | OTHER |