Provider Demographics
NPI:1932542545
Name:SMEDEMA, AMY BETH (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BETH
Last Name:SMEDEMA
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 1:632 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3512
Mailing Address - Country:US
Mailing Address - Phone:920-217-4959
Mailing Address - Fax:
Practice Address - Street 1:632 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3512
Practice Address - Country:US
Practice Address - Phone:920-217-4959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1961-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant