Provider Demographics
NPI:1336664754
Name:HENKE, AMANDA M (DPT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:HENKE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:STAFFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1155 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-5990
Mailing Address - Fax:414-955-6282
Practice Address - Street 1:1155 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-5990
Practice Address - Fax:414-955-6282
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13903-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist