Provider Demographics
NPI:1235383803
Name:FERG, AMANDA LYNN (BS, PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:FERG
Suffix:
Gender:F
Credentials:BS, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 W GREEN TREE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTONVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54929-1009
Mailing Address - Country:US
Mailing Address - Phone:715-823-2194
Mailing Address - Fax:715-823-1303
Practice Address - Street 1:70 W GREEN TREE RD
Practice Address - Street 2:
Practice Address - City:CLINTONVILLE
Practice Address - State:WI
Practice Address - Zip Code:54929-1009
Practice Address - Country:US
Practice Address - Phone:715-823-2194
Practice Address - Fax:715-823-1303
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1220-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1220-019OtherPTA LICENSING NUMBER