1164721536 NPI number — AMY L MACK SINDELAR SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164721536 NPI number — AMY L MACK SINDELAR SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SINDELAR
Provider First Name:
AMY
Provider Middle Name:
L MACK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MACK
Provider Other First Name:
AMY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164721536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13800 W NORTH AVE
Provider Second Line Business Mailing Address:
CHILD DEVELOPMENT CENTER
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53005-4977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-432-6600
Provider Business Mailing Address Fax Number:
262-432-6604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13800 W NORTH AVE
Provider Second Line Business Practice Location Address:
CHILD DEVELOPMENT CENTER
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53005-4977
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-432-6600
Provider Business Practice Location Address Fax Number:
262-432-6604
Provider Enumeration Date:
03/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  3493 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1164721536 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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