Provider Demographics
NPI:1902070543
Name:ELDER, AMY JO (PTA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:ELDER
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:S142 STATE ROAD 33
Mailing Address - Street 2:
Mailing Address - City:WONEWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53968-9642
Mailing Address - Country:US
Mailing Address - Phone:608-393-1617
Mailing Address - Fax:608-524-9181
Practice Address - Street 1:S142 STATE ROAD 33
Practice Address - Street 2:
Practice Address - City:WONEWOC
Practice Address - State:WI
Practice Address - Zip Code:53968-9642
Practice Address - Country:US
Practice Address - Phone:608-393-1617
Practice Address - Fax:608-524-9181
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant