Active NPI
Amy Formella, MT-BC
- Music Therapist
- King, WI
National Provider Identifier
1295586402
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Music Therapist
- License
- 11736
- Practice address
- 800 Mitchell Ave
King, WI 54946-0601 - Phone
- (715) 258-5586
- NPI assigned
- Mar 27, 2024
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Music Therapist | 225A00000X | 11736 | WI | Primary |
Addresses
Primary practice location
800 Mitchell Ave
King, WI 54946-0601
Mailing address
800 Mitchell Ave
King, WI 54946-0601
Phone (715) 258-5586
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11736 | WI | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1711497600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1711497600000",
"number": "1295586402",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "800 MITCHELL AVE",
"city": "KING",
"state": "WI",
"postal_code": "549460601",
"telephone_number": "715-258-5586"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "800 MITCHELL AVE",
"city": "KING",
"state": "WI",
"postal_code": "549460601",
"telephone_number": "715-258-5586"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FORMELLA",
"first_name": "AMY",
"credential": "MT-BC",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2024-03-27",
"last_updated": "2024-03-27",
"certification_date": "2024-03-27",
"status": "A"
},
"taxonomies": [
{
"code": "225A00000X",
"taxonomy_group": "",
"desc": "Music Therapist",
"state": "WI",
"license": "11736",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in King, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 27, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.