Provider Demographics
NPI:1821477399
Name:EVERSON, AMANDA JOY (LMT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JOY
Last Name:EVERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 REFSET DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0462
Mailing Address - Country:US
Mailing Address - Phone:608-609-0728
Mailing Address - Fax:
Practice Address - Street 1:1504 REFSET DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0462
Practice Address - Country:US
Practice Address - Phone:608-609-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10910-146172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist