Provider Demographics
NPI:1689841918
Name:THOR, AMANDA S (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:THOR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:LEROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:3014 ERIE AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3658
Mailing Address - Country:US
Mailing Address - Phone:920-459-3028
Mailing Address - Fax:
Practice Address - Street 1:3014 ERIE AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3658
Practice Address - Country:US
Practice Address - Phone:920-453-7087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1165019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant