Provider Demographics
NPI:1104092253
Name:EIDEN, AMY (OTR)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:
Last Name:EIDEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 PRAIRIE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1947
Mailing Address - Country:US
Mailing Address - Phone:262-612-2855
Mailing Address - Fax:262-612-2893
Practice Address - Street 1:10330 PRAIRIE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1947
Practice Address - Country:US
Practice Address - Phone:262-612-2855
Practice Address - Fax:262-612-2893
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2574-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40829700Medicaid