Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation | 056.009755 | IL |
NPI | 1336490754 |
---|---|
Provider Name | Amy Renee Niewald |
First Address | Alton, IL 62002-6722 |
Second Address | Alton, IL 62002-6722 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2012 |
Last Update Date | 25/09/2012 |