Provider Demographics
NPI:1447855994
Name:SUSA, AMANDA LAUREN (OTR)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LAUREN
Last Name:SUSA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LAUREN
Other - Last Name:HOOPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 PINE RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4102
Practice Address - Country:US
Practice Address - Phone:715-847-2826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6895-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist