Provider Demographics
NPI:1194008219
Name:ANDERSON, AMY S (PT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2396
Mailing Address - Country:US
Mailing Address - Phone:715-309-8045
Mailing Address - Fax:
Practice Address - Street 1:2901 MEADOWBROOK LN
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2396
Practice Address - Country:US
Practice Address - Phone:715-309-8045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-25
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6161-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist