Provider Demographics
NPI:1407338924
Name:BASSO, AMANDA KAY
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:BASSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2263 WILMOT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-2332
Mailing Address - Country:US
Mailing Address - Phone:262-417-6845
Mailing Address - Fax:
Practice Address - Street 1:7500 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53213-1717
Practice Address - Country:US
Practice Address - Phone:414-258-6170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2811-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant