Provider Demographics
NPI:1174773527
Name:LONDT, AMBER (OTR, PTA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:LONDT
Suffix:
Gender:F
Credentials:OTR, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 REGENCY CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-6168
Mailing Address - Country:US
Mailing Address - Phone:262-798-9650
Mailing Address - Fax:262-798-9652
Practice Address - Street 1:275 REGENCY CT
Practice Address - Street 2:SUITE 200
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-6168
Practice Address - Country:US
Practice Address - Phone:262-798-9650
Practice Address - Fax:262-798-9652
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI267-019225200000X
IN06002835A225200000X
WI4466-026225X00000X
IN31004485A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN31004485AOtherOCCUPATIONAL THERAPIST INDIANA LICENSE
WI4466-026OtherOCCUPATIONAL THERAPIST STATE LICENSE/PTA STATE LICENSE
IN06002835AOtherPTA INDIANA LICENSE
WI267-019OtherPTA STATE LICENSE