Provider Demographics
NPI:1750957890
Name:BECKENDORF, AMANDA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:BECKENDORF
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 NORTH CT APT 307
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-3710
Mailing Address - Country:US
Mailing Address - Phone:608-769-1658
Mailing Address - Fax:
Practice Address - Street 1:323 BLACK RIVER AVE
Practice Address - Street 2:
Practice Address - City:WESTBY
Practice Address - State:WI
Practice Address - Zip Code:54667-1127
Practice Address - Country:US
Practice Address - Phone:608-634-3747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-30
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1832225200000X
WI2154225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant