Provider Demographics
NPI:1952705790
Name:HAFERMAN, AMY (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:HAFERMAN
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 1:5721 HONEYSUCKLE CT
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-7231
Mailing Address - Country:US
Mailing Address - Phone:715-572-1813
Mailing Address - Fax:
Practice Address - Street 1:5721 HONEYSUCKLE CT
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-7231
Practice Address - Country:US
Practice Address - Phone:715-572-1813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1595-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant