Provider Demographics
NPI:1730828088
Name:PRUSOW, AMANDA GRACE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:PRUSOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2639
Mailing Address - Country:US
Mailing Address - Phone:920-889-6510
Mailing Address - Fax:
Practice Address - Street 1:1155 QUAIL CT STE 100
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3780
Practice Address - Country:US
Practice Address - Phone:262-404-6153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1282-140103K00000X
103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst