Provider Demographics
NPI:1164706511
Name:HAVERKORN, AMY JO (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:HAVERKORN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:LEGRAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2763 MANITOWOC RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6633
Mailing Address - Country:US
Mailing Address - Phone:920-468-8288
Mailing Address - Fax:920-468-9887
Practice Address - Street 1:2763 MANITOWOC RD
Practice Address - Street 2:SUITE B
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6633
Practice Address - Country:US
Practice Address - Phone:920-468-8288
Practice Address - Fax:920-468-9887
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI223-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI223-19OtherLICENSE NUMBER