Basic Information
Provider Information | |||||||||
NPI: | 1235474123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLAHERTY | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MOTR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STORY | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 430 E DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549354560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209265390 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 430 E DIVISION ST | ||||||||
Address2: |   | ||||||||
City: | FOND DU LAC | ||||||||
State: | WI | ||||||||
PostalCode: | 549354560 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9209265390 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2012 | ||||||||
LastUpdateDate: | 12/03/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4835-26 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
No ID Information.