Provider Demographics
NPI:1962977736
Name:STUMLIN, AMBER MAE (COTA/L)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:MAE
Last Name:STUMLIN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HATTAN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:WI
Mailing Address - Zip Code:54614-8862
Mailing Address - Country:US
Mailing Address - Phone:608-386-8216
Mailing Address - Fax:
Practice Address - Street 1:14345 COUNTY HIGHWAY B
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-4509
Practice Address - Country:US
Practice Address - Phone:608-269-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5532-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant