Provider Demographics
NPI:1386706455
Name:EVENSTAD, AMY (OTR)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:EVENSTAD
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:N496 COUNTY ROAD PI
Mailing Address - Street 2:
Mailing Address - City:COON VALLEY
Mailing Address - State:WI
Mailing Address - Zip Code:54623-9374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2575 7TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5249
Practice Address - Country:US
Practice Address - Phone:608-775-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1489-027224Z00000X
WI4511-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1489-027OtherCOTA LICENSE