Provider Demographics
NPI:1477048882
Name:BERANEK, AMY SUE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:SUE
Last Name:BERANEK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:SUE
Other - Last Name:YOLITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:232365 PEBBLESTONE RD
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403
Mailing Address - Country:US
Mailing Address - Phone:715-432-1833
Mailing Address - Fax:
Practice Address - Street 1:4810 BARBICAN AVE
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476
Practice Address - Country:US
Practice Address - Phone:715-393-0419
Practice Address - Fax:715-359-0938
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2763-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant