Basic Information
| Provider Information | |||||||||
| NPI: | 1902183429 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUSALACCHI | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | YEKO | ||||||||
| OtherFirstName: | AMY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1703 60TH ST | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531403986 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1703 60TH ST | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531403986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626584125 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2011 | ||||||||
| LastUpdateDate: | 11/11/2011 | ||||||||
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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 | 225X00000X | 509226 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.