Basic Information
Provider Information | |||||||||
NPI: | 1902070543 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ELDER | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | S142 STATE ROAD 33 | ||||||||
Address2: |   | ||||||||
City: | WONEWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 539689642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083931617 | ||||||||
FaxNumber: | 6085249181 | ||||||||
Practice Location | |||||||||
Address1: | S142 STATE ROAD 33 | ||||||||
Address2: |   | ||||||||
City: | WONEWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 539689642 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083931617 | ||||||||
FaxNumber: | 6085249181 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2008 | ||||||||
LastUpdateDate: | 04/25/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 251-019 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.