Provider Demographics
NPI:1104125020
Name:HIGGINBOTHAM, AMY M (MS)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:HIGGINBOTHAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:BAUDHUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941-0588
Mailing Address - Country:US
Mailing Address - Phone:920-294-4070
Mailing Address - Fax:920-294-4139
Practice Address - Street 1:571 COUNTY ROAD A
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941-8630
Practice Address - Country:US
Practice Address - Phone:920-294-4070
Practice Address - Fax:920-294-4139
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health