Provider Demographics
NPI:1134490618
Name:THOMPSON, AMY SUSAN (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SUSAN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:SUSAN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-948-3622
Mailing Address - Fax:
Practice Address - Street 1:7610 PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4318
Practice Address - Country:US
Practice Address - Phone:262-948-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-16
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1825225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant