Basic Information
| Provider Information | |||||||||
| NPI: | 1255487260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 521 AUSTGEN PL | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198644338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 MACARTHUR BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198361600 | ||||||||
| FaxNumber: | 2198366752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31002155A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200830400 | 05 | IN | MEDICAID | 200713210A | 05 | IN | MEDICAID | 200614560 | 01 | IN | FIRST STEPS | OTHER |