Provider Demographics
NPI:1104895564
Name:SIMPSON, AMANDA J (PT)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:J
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S SEGOE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1023
Mailing Address - Country:US
Mailing Address - Phone:608-228-4340
Mailing Address - Fax:
Practice Address - Street 1:4602 EASTPARK BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2002
Practice Address - Country:US
Practice Address - Phone:608-440-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4295-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41810600Medicaid
WI363382403OtherTAX ID NUMBER
WI526556Medicare ID - Type UnspecifiedMEDICARE