Provider Demographics
NPI:1245331586
Name:MORK, AMANDA M (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:MORK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2500 N MAYFAIR RD
Mailing Address - Street 2:STE 500
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2835 N GRANDVIEW BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5531
Practice Address - Country:US
Practice Address - Phone:262-574-5185
Practice Address - Fax:262-574-5193
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI000683042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist