Basic Information
| Provider Information | |||||||||
| NPI: | 1245458918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTHEARDT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | O.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 15312 W BELOIT RD | ||||||||
| Address2: | |||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626415117 | ||||||||
| FaxNumber: | 2626416317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2007 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4342-26 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1056173 | 01 | OTR | OTHER | 4342-26 | 01 | WI | LICENSE O.T. | OTHER | 41047700 | 05 | WI | MEDICAID |