Basic Information
| Provider Information | |||||||||
| NPI: | 1831468503 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ST.JOHN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 KARL AVE | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535089700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084455620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2448 SOUTH 102ND ST | ||||||||
| Address2: | STE 340 MJ CARE INC | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143292500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2011 | ||||||||
| LastUpdateDate: | 12/23/2011 | ||||||||
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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 | 4751-27 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 224Z00000X | 057003295 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.