Provider Demographics
NPI:1659585172
Name:BECK, AMANDA L (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BECK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:GLOCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2448 S 102ND ST STE 340
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2147
Mailing Address - Country:US
Mailing Address - Phone:800-776-7016
Mailing Address - Fax:
Practice Address - Street 1:400 E. 4TH STREET
Practice Address - Street 2:
Practice Address - City:MANAWA
Practice Address - State:WI
Practice Address - Zip Code:54961
Practice Address - Country:US
Practice Address - Phone:800-776-7016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1307-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant