Provider Demographics
NPI:1649254277
Name:ROE, AMY A (MPT, DPT)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:A
Last Name:ROE
Suffix:
Gender:F
Credentials:MPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3064 COVINGTON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-7208
Mailing Address - Country:US
Mailing Address - Phone:605-787-2719
Mailing Address - Fax:605-718-4452
Practice Address - Street 1:3064 COVINGTON ST STE 104
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-7208
Practice Address - Country:US
Practice Address - Phone:605-787-2719
Practice Address - Fax:605-718-4452
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5842190Medicaid
SDS108985Medicare UPIN
SD5842190Medicaid
SD1285925453Medicare NSC