Provider Demographics
NPI:1811930050
Name:HAHN, AMBER J (PT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:J
Last Name:HAHN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:J
Other - Last Name:DEVINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:421 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935
Mailing Address - Country:US
Mailing Address - Phone:920-923-7940
Mailing Address - Fax:
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-923-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2003-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40073800Medicaid