Provider Demographics
NPI:1720304777
Name:SORDAHL, AMY J (MSPT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:SORDAHL
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6044 SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MANAWA
Mailing Address - State:WI
Mailing Address - Zip Code:54949-9127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1405 MILL ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2155
Practice Address - Country:US
Practice Address - Phone:920-531-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62592081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine