Provider Demographics
NPI:1457694739
Name:BECKSTROM, AMY DIANE (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DIANE
Last Name:BECKSTROM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:DIANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:470 ACOMA BLVD S
Mailing Address - Street 2:#136
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7799
Mailing Address - Country:US
Mailing Address - Phone:928-412-5100
Mailing Address - Fax:
Practice Address - Street 1:2781 OSBORN DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-8629
Practice Address - Country:US
Practice Address - Phone:928-505-5552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10146A225200000X
TX2095570225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant