Provider Demographics
NPI:1245458918
Name:GOTTHEARDT, ANDREW E (OTR/L, CHT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:E
Last Name:GOTTHEARDT
Suffix:
Gender:M
Credentials:OTR/L, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD UNIT 206
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8711
Mailing Address - Country:US
Mailing Address - Phone:009-744-3788
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:10320 75TH ST STE D
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7525
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4342-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1056173OtherOTR
WI4342-26OtherLICENSE O.T.
WI41047700Medicaid
WI4342-26OtherLICENSE O.T.
1056173OtherOTR
WI864540013Medicare PIN
WI000085185Medicare PIN